There is a reason that pediatric dentist offices across the country are outfitted with video games, movies, iPads and treasure chests of prizes for a successful visit. Dentists know as well as the rest of us that a trip to their office ranks pretty low on kid’s list of fun. They work hard to try and create an inviting environment that makes the experience more positive. As parents we know that it is important for our kids to brush and floss. We have read the articles about how poor dental hygiene is linked to other health problems, and we have heard the dentist say that if you don’t start brushing regularly then you are going to get cavities. The thought of cavities is enough to strike fear into me and it’s hard enough for my son to handle a simple cleaning - let alone the idea that someone might be drilling in his mouth. After our last disastrous visit, where we had to hold him down just for the cleaning, we began working with his Applied Behavior Analysis (ABA) provider on a social story and we have been playing dentist to practice for his next appointment.
The Challenges of Toothbrushing
We have also been working on toothbrushing and flossing at home in hopes of keeping any dental issues at bay. When you have a child with autism, you are up against several challenges when it comes to brushing and flossing. Take a moment and think about it: you are sticking something into your child’s mouth which sets off all sorts of sensory alarm bells. The toothbrush has a paste on it that tastes, smells and feels weird. You are trying to make sure that they clean an entire mouth full of teeth following several steps and over a period of ideally two minutes. In addition, you know that if you don’t conquer this challenge, you are going to need to go to the dentist for more than just a cleaning which ratchets up your anxiety and only makes you push harder, leading to power struggles! For some kids the sensory challenges might be the biggest hurdle, for others it could be the executive functioning required and knowing the steps. For others it might be the challenge of staying on task, or the fine motor skills needed to get the mechanics of brushing down; for others it is some combination of these factors. It is important to evaluate and know what the challenges are for your child so that you can appropriately address them.
A Dental Confession
I am going to pause here for a moment of honesty and admit that I would be lying if I told you that we have conquered the toothbrushing struggles in our house, but we have made some progress and I am happy to share some of our specific challenges and the strategies we have found for success.
First of all, we know that in our house routine and consistency are critical. As with many things, we have embedded toothbrushing into regular routines. It is part of our morning routine every day and it is part of the bedtime routine every night. My son isn’t thrilled with toothbrushing, but he knows what to expect and that is an important first step.
It is pretty clear that my son has some sensory challenges which have an impact on toothbrushing. We have noticed that toothbrushing gets more challenging when he has a loose tooth (he gets anxious it will get knocked out) or as a new tooth is growing in (seems to be more sensitive). Luckily for us, he is okay with toothpaste flavor and texture, but this is something to certainly keep in mind when trying different flavors if your child is sensitive to the taste. We have tried many different toothbrushes - we started with regular ones that had cool characters on them which made it somewhat more interesting. Once using a regular brush was tolerated, we were able to try out an electronic one. Again, small steps: we didn’t turn it on for a while and even now we just turn it on for a short period of time. As an aside, we moved to the electronic one at the dentist’s recommendation as a way to help get used to the noise and vibration which will happen as part of the cleaning in their office.
The “Closed Mouth Power Struggle”
Another battle around toothbrushing that we have had to work on is what I affectionately refer to as the “closed mouth power struggle.” This most frequently occurs when he is tired or he has another preferred activity that he is being denied in an effort to get toothbrushing done. We are very conscious of timing when engaging in the bedtime routine and not letting it creep into his tired zone! The other preferred activity requires some creativity - we either have to figure out how to distract from it (you can listen to music or use an app or watch a video while brushing) or how to use it as a reward (as soon as you are done brushing you can play with that toy, read the book etc.).
Speaking of rewards, it is important to think about what motivates your child. For my son, he loves all things electronic. ABA had been working with him on a program where he could check off on their iPad when he did a task independently and he really liked this. We translated this to the Goally where we created a routine that broke down each step and he could mark off when he completed it. This worked for awhile until he lost motivation - this is another one of our struggles - what works one day doesn’t necessarily work the next! We have learned that we have to change up rewards and finding ways to motivate him and rotate through what we've learned works.
We then tried a few apps that would show him the steps and act as a timer. There are free ones and there are ones that you can purchase as well. We had success with Brusheez and more recently with Brush DJ. Brusheez is an app that has a timer, but also has a visual that shows you where to brush. It plays a strange tune that the kids love. You can change the character’s hair and clothing color. It also allows you to customize the visual of the mouth to show where you are missing teeth! Brush DJ is not super fancy, but it does have a timer and it allows you to play a song from your phone that you can choose. Brushing to songs from Disney movies and classic rock does seem to be motivational these days in our house!
A Few Final Words of Wisdom
Take small steps: if just getting the toothbrush in the mouth is a fight, then reward the little successes and build on them. Don’t expect perfection - remember you are teaching a life skill and this can take time. We still do “teeth checks” at least once a day and follow his brushing attempt with us doing a quick brush. This way he is learning to brush, but we are making sure that there is a bit of quality brushing happening. If one technique doesn’t work, then get creative and try a different approach. Give choices (which brush to use, which flavor of toothpaste, etc.). Humor helps everyone. We went through a period of time where I told a story about “George the Sugar Bug” as he was brushing and we pretended to try to catch George as he jumped around my son’s mouth. This led to a lot of giggles and was far more fun for both of us than just telling him where to brush! George still makes an appearance on occasion when we are having a rough day! Last, but not least, give yourself a break. These struggles are real, and can be super frustrating. If a toothbrushing session doesn’t go well and not every tooth gets a perfect cleaning, the world will not end. Take a deep breath and let it go for the moment, you will have plenty of chances to try other approaches and to keep learning what works best for your child.
Cambria Walsh is a working mom of 7-year-old twin boys who are both on the autism spectrum. When she isn’t parenting she trains professionals on the impact of trauma on individuals and organizations.
Editor's note: This information is not meant to diagnose or treat and should not take the place of personal consultation, as needed, with a qualified healthcare provider and/or BCBA.