Alternatives: A review of non-pharmacologic approaches to increasing the cooperation of patients with special needs to inherently unpleasant dental procedures.

Abstract

Applied Behavior Analysis (ABA) has addressed many problems of social significance. Illustrating one such problem, dental patients with special needs sometimes physically resist needed treatments. Treatment options include medications, mechanical or physical restraints, or attempts to overcome resistance behaviorally. This paper reviews alternative behavioral approaches to decreasing resistance and increasing cooperation. Common characteristics of effective treatments are outlined and their limitations discussed. Key words: behavioral dentistry, applied behavior analysis, alternatives to sedation I. INTRODUCTION Applied behavior Analysis (ABA) has always attempted to provide empirically-based solutions to problems of social significance in the real world. And, from its inception, ABA has specifically addressed behavior change in persons with special needs--e.g., children, the developmentally disabled and autistic, the mentally ill, persons with traumatic brain injury and other disabilities. One area that has received considerable (and cross-disciplinary) attention has been the fact that some children and adults with special needs exhibit physical resistance to daily oral hygiene and to needed dental treatments, especially when daily oral hygiene tasks are less than pleasant; and when those dental treatments are provided in strange and unfamiliar environments, and when the treatments themselves are inherently intrusive, aversive and painful (e.g., examinations, injections, extractions). The literature provides ample evidence that a behavioral approach to resistance to dental treatment can accomplish two important goals. First, a patient's physical resistance can be reduced during treatment, thus allowing that particular treatment to be completed. Second, and more importantly, a behavioral approach can transcend the immediate treatment situation and can be implemented in such a way that the individual actually learns to increase cooperation with dental treatment in the future, thus making later treatment easier. Concomitantly, at least some children and persons with special needs will gain in overall quality of life, increased oral hygiene skill levels, and self-control and in their ability to tolerate unpleasant situations.. In many cases and for many patients exhibiting mild to moderate physical resistance, it will be possible to complete dental treatment, even an extended series of treatments, by implementing one or more of the interventions described below. However, there will almost always be a minority of individuals who will not respond with cooperation even when multiple positive interventions are implemented. In some cases, this may be due to extreme resistance on the part of the patient; in other cases, it may be due to the inherently painful nature of the treatment. In these circumstances, we are faced with an interesting ethical dilemma. We know that the first rule of service provision is to no harm. Sometimes that decision is clear-cut and easy to make (e.g., an impacted tooth needs to be extracted; an acute dental injury requires immediate treatment). When patients resist, however, the determination of harm is less obvious. On the one hand, we avoid immediate harm by fudging oral hygiene skill training, and by avoiding treatment for the patient. But, over time, lack of daily hygiene and dental treatment results in increasingly poor oral hygiene, which may require more intrusive (i.e., an increased possibility of more intrusive, possibly dangerous, and certainly expensive) treatment in the future. The question is not whether we do harm; rather, the question is when harm will be done, and how best to minimize that harm. This is a particularly interesting question given that various regulatory agencies on the one hand require individuals with special needs to be provided with daily oral hygiene and with regular dental examinations and treatments as needed, and yet those same regulatory agencies also place significant impediments (and even negative consequences) in the way of such practices. …