Our son Joshua has always had a beautiful smile! It was so heartbreaking when the aggression and self injurious behaviors increased to the point that major damage was done to his teeth. Most families that have children with intellectual/developmental disabilities, especially autism, know that dental treatment can be a challenge even under the best of circumstances. Before Josh went to inpatient treatment in 2018, We sought a dentist for months and only found long waiting lists and rejection for treatment. Now, we have found a great solution involving an alternative to general anesthesia, which is dangerous for Joshua, that we wanted to share with you. —Vance Goforth
The papoose board features a tight velcro wrap, and fits on a standard dental chair.
The following was written by Nellie Gannon, DMD, Director of Dental Services, Orange Grove Center Dental Clinic, Tennessee.
Joshua first came to Orange Grove Center Dental Clinic about 3 weeks ago. His parents were concerned that one of his front teeth were bothering him as he kept pointing to them, but he had never been seen in a dental clinic without general anesthesia. At Orange Grove, our goal is to avoid general anesthesia as much as possible. Especially with individuals with special needs, it can have many risks. Although we know that sometimes that is the only option we have, we utilize many methods to avoid this. One of them is desensitization, which is a way for patients to get slowly more used to the dental office through sometimes multiple visits. We also use the “tell-show-do” method, which helps our individuals understand what we are doing and engage them more in the process. These techniques allow them to gradually learn that we are there to help them and work with them and feel safe.
When necessary, we use the papoose board. The papoose is a means to protect the patient and providers from potentially harmful movement. If a patient is attempting to grab instruments, it could be dangerous to the patient and the people around them. The papoose serves as a means to safely stabilize an individual that may attempt to move during dental treatment in a way that is unsafe, while allowing them to be seen awake without the health risks general anesthesia can have.
Joshua first came into the dental clinic with no issue. As we were told he never had been seen at the dentist while he was awake, we opted to use the papoose with the consent of his parents. We look at each patient and each appointment to determine whether or not protective stabilization, such as the papoose, is needed in order to allow for the least restrictive means possible. We learned that Joshua enjoys Christian music, and had it playing as he walked in to make sure he was somewhere he felt comfortable and welcome. He walked around our clinic, which includes a Jukebox, a PacMan machine, and TVs above the operatories where patients can watch whatever they want. He got into the papoose with the help of myself, my assistant, and Joshua’s caregiver. He was resistant at first but seemed comfortable once he was laying down and secure.
After he was in the papoose we did his comprehensive exam, which includes looking at his teeth and taking x-rays. He would move his head at times when we touched areas that were sensitive, but we were able to complete the full exam and determine the next steps. With the need for extensive dental work, we decided to continue using the papoose for appointments for the time being. He left his first dental appointment he was awake for alert and happy, especially after he got a prize at the end. His mother told us how shocked and happy she was we got everything done, and we were all very thankful that we were able to complete his first visit successfully.
I have seen Joshua three times so far. Since his first visit, we have been able to complete an extraction, a large filling, and deep cleanings throughout his mouth. He comes in and we have the Christian music ready, the TV on, and a prize waiting for him when he is done. Each visit his behavior has improved, as his oral health improves and his teeth and gums feel better. He has so far come into the clinic and left with no issues. We still have extensive work to complete, but my hope is to finish all his dental work in a timely manner and to continue to see him get more acclimated to the dentist. Each visit he seems more comfortable is a success for all of us.
At Orange Grove, there is an approval process to allow for the use of the papoose. I first got some articles regarding its safety and effectiveness in dental treatment, and safety compared to general anesthesia. This went through a Human Rights Committee with the help of our director, where we explained why, when and how we would use it. We made sure to let everyone know it is not used as a way to make an appointment easier, but a way to make our patients safer. After this was approved by the Committee, the dental staff watched videos and modules to learn how to use it. I trained them on my own, as well as with our behavior analyst. Each of us got into it to see what it was like, and to understand how to place a patient in it in a comfortable way. We have consent paperwork that allows a patient’s conservator the option to learn about it and allow the use of protective stabilization or not, and they have the option to revoke this consent at any time. When caregivers are present during appointments while it is used, we make sure to educate them about why we use it at the office.
“Right now, the papoose is the least restrictive means to see Joshua safely.”
Our goal for Joshua and all our patients is for them to be seen in the most comfortable and least restrictive environment as possible. Right now, the papoose is the least restrictive means to see Joshua safely. We will continue to observe each visit to determine if at some point we may not need it. For some patients, they choose to be seen with it, as it works similar to a weighted blanket. It can provide for sensory needs and can also serve as a sense of security. If that is what the patient wants, that’s what we do.
The dentist can be a scary place, and we want to serve our patients as best as we possibly can. I am so happy and thankful that we are able to see Joshua in a safe, enjoyable dental setting where he and his parents feel that dental needs are getting met.
[Further from Vance]
We’re so grateful for Orange Grove and for providing a safe and effective way for Josh to have dental procedures done; but most of all, for working so hard to gain his trust! It’s time that we move beyond the traditional “shoebox” approach to services, treatments and research for severe autism. We need to realize that what may seem restrictive to one individual may be the least restrictive and comforting to someone else. The use of the papoose has been a wonderful solution for Joshua that provided a much better experience and outcome versus Joshua having general anesthesia, which triggers behavioral outbursts during recovery.
If we truly believe the statement “If you've met one individual with autism, you've met one individual with autism,” then we must realize and work toward solutions that are also focused on the individual, especially for those with severe autism. If we don’t, then this statement becomes nothing more than another cliché.
Vance Goforth is an autism dad who lives in Tennessee.