Journal of Developmental and Physical Disabilities (2019) 31:161–170

https://doi.org/10.1007/s10882-018-9635-8
ORIGINAL ARTICLE

Dental Desensitization for Students with Autism

Spectrum Disorder through Graduated Exposure,
Reinforcement, and Reinforcement-Fading

Lauren Carter 1 & Jill M. Harper 1 & James K. Luiselli 1

Published online: 16 October 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Many persons with intellectual and developmental disabilities resist basic dental care
leading to poor oral health. The present study evaluated the effects of a dental
desensitization intervention for two students who had autism spectrum disorder and
would not tolerate tooth cleaning and examination. Intervention consisted of gradually
exposing the students to steps within a desensitization hierarchy, reinforcing compli-
ance, and progressively fading-eliminating reinforcement. Familiar care-providers im-
plemented intervention within a simulated dental setting at their school. Both students
completed intervention successfully and one of them was able to tolerate procedures
during visits to a dentist’s office. We discuss the clinical and research implications of
these findings.

Keywords Autism spectrum disorder . Desensitization . Dental care . Graduated exposure .

Positive reinforcement

Many children and adults who have intellectual and developmental disabilities (IDD)
do not visit a dentist regularly to receive basic dental care (Kancherla et al. 2013;
Petrovic et al. 2016). Poor oral health can lead to untreated caries, periodontal disease,
and gingivitis (Owens et al. 2006; Turner et al. 2007). In particular, the oral health of
individuals with autism spectrum disorder (ASD) may suffer due to uncooperative

* Lauren Carter
lcarter@melmarkne.org

Jill M. Harper
jharper@melmarkne.org
James K. Luiselli
jluiselli@melmarkne.org

1
Melmark New England, 461 River Road, Andover, MA 01810, USA
162 Journal of Developmental and Physical Disabilities (2019) 31:161–170

behavior and intolerance during dental examinations (Loo et al. 2008). Parents, for
example, report that their children with ASD complain about and dislike dental office
visits, resist dental procedures, and respond negatively to oral care at home (e.g., tooth
brushing, flossing) (Stein, Polido, & Cermak, 2012). Unfortunately, these problems
may cause some dentists to refuse treatment of patients who have ASD and other
neurodevelopmental disorders (Clevenger et al. 1993; Hernandez and Ikkanda 2011).
Furthermore, in extreme cases, professionals may resort to invasive methods such as
sedation and physical restraint in order to complete a dental examination (Duker et al.
2017; Stein et al. 2014).
Among several behaviorally-based procedures to reduce and eliminate dental
resistance in persons with IDD, researchers have reported success through different
desensitization methods combined with additional supports. For example, Maguire
et al. (1996) targeted four adults with intellectual disability who were noncompliant
during dental examinations. The intervention objectives in the study were teaching the
adults to sit quietly in a dentist’s chair, keep hands on lap, open mouth when required,
and tolerate examination procedures. Following a baseline phase in a multiple baseline
across participants design, researchers implemented a seven-component intervention
plan consisting of demonstration, gradual exposure, social and monetary reinforcement,
and continuous access to hand-held preferred objects. During and following
intervention, all of the adults were able to tolerate dental treatment without resistance
or problem behaviors.
Altabet (2002) reported effective desensitization to dental examination and cleaning
procedures with 35 individuals who had intellectual disability. The treatment partici-
pants in a group comparison design were slowly exposed to a 34-step examination-
cleaning hierarchy, initially to steps they tolerated most comfortably, followed by steps
they resisted more frequently. Modelling, shaping, relaxation, and positive reinforce-
ment procedures were also implemented during treatment sessions. Compared to a non-
treatment group, the treatment participants completed significantly more of the dental
procedures within the complete examination-cleaning hierarchy.
In a study by Conyers et al. (2004), the participants were six adults who had
intellectual disability and demonstrated extreme problem behaviors that interfered with
dental examinations. Their compliance with 18 dental procedures was measured during
baseline and intervention phases in a multiple baseline across participants design. Three
of the six adults started intervention with in vivo desensitization in which a trainer
prompted each dental procedure and delivered encouragement and praise when they
Bappeared relaxed and calm.^ All of the adults were eventually able to tolerate dental
examination. Intervention for the other three adults started with them watching a video
model of a familiar person responding compliantly to the dental procedures and
receiving praise. This form of video modelling (Nikopoulos et al. 2016) was effective
with one of the adults but the remaining adults required the in vivo desensitization
intervention to achieve success.
Finally, Cuvo et al. (2010) evaluated a multicomponent intervention to increase
compliance with dental procedures among children with ASD. The study combined
visual priming, stimulus fading, escape extinction, distraction, and differential
reinforcement with consistent positive outcome. As well, there was generalization
from simulated to natural settings and across multiple individuals conducting dental
examinations.
Journal of Developmental and Physical Disabilities (2019) 31:161–170 163

In summary, the results of previous research support desensitization interventions for

improving tolerance of dental procedures in children and adults with IDD and
neurodevelopmental disorders. All studies evaluated intervention during simulated
sessions, sometimes assessing generalization to actual dental settings. Concerning
intervention implementation, Conyers et al. (2004) proposed that Bfuture research
should evaluate ways to make desensitization procedures more efficient^ (p.237) by
(a) designing a mock dental office on-site at service settings, and (b) examining various
parameters of desensitization that optimize application. Towards these objectives, the
rationale for the present study was evaluating a dental desensitization program with two
students who had ASD and lived in a residential school, having familiar care-providers
implement procedures in a simulated dentist’s office, and combining graduated expo-
sure, positive reinforcement, and reinforcement fading in a systematic and abbreviated
intervention protocol.

Method

Participants and Setting

The participants were two male students who attended a residential school for children
and youth who had neurodevelopmental disorders. Jason was 10-years old and had
been diagnosed with ASD. He did not speak, used gestures to initiate communication,
and could follow simple one-step instructions. Jason required assistance from care-
providers to complete most self-care and daily living skills. Luke was 18-years old and
had been diagnosed with ASD. He was non-verbal and communicated through gestures
and non-speech devices. Luke needed care-provider support to complete self-care and
daily living skills.
Both Jason and Luke resisted dental examinations and having their teeth cleaned.
Jason typically refused to sit in the dentist’s chair, dropping to the floor, and if verbally
encouraged to a sitting position, would not open his mouth when requested. Luke
would not independently enter a dentist’s office, needed physical prompting, but would
not comply with procedures. Neither Jason or Luke had participated in a formal
intervention to reduce their resistance and improve tolerance with dental examina-
tion-cleaning.
Baseline and intervention sessions were conducted in a room at the school which
had been prepared to resemble a dentist’s office. The room was equipped with a
standard dentist chair and related materials which included an electric tooth brush,
floss stick, dental utensils, and bib with disposable paper strip around the neck.

Measurement

The dependent measure was the percentage of steps Luke completed independently
according to a 38-step task analysis (Table 1) and the percentage of steps Jason
completed independently according to a slightly modified version of the task analysis
comprised of 32 steps (elimination of steps Brinses mouth with water^ and Bspits water
out^). The task analysis covered three response-sets of completing dental examination-
cleaning: (a) entering the dentist’s office and sitting in the chair (Set 1), (b) counting
164 Journal of Developmental and Physical Disabilities (2019) 31:161–170

Table 1 Dental desensitization task analysis

Steps Description

1 Walks into the Boffice^ (e.g. room with dental chair)

2 Walks towards dental chair
3 Touches dental chair (staff places edible on chair-when he picks up the
edible it counts as touching the chair when appropriate to set)
4 Sits to the side on the edge of the dental chair (feet to the side of chair)
5 Sits on the edge of the dental chair (feet in front of him facing outward)
6 Pushes self back into the dental chair
7 Allows bib to be placed around neck
8 Leans back into the dental chair
9 Opens mouth
10 Accepts utensil inserted into mouth
11 Allows therapist to count bottom teeth for 20s
12 Opens mouth
13 Accepts utensil inserted into mouth
14 Allows therapist to count top teeth for 20s
15 Opens mouth
16 Accepts toothbrush inserted into mouth
17 Allows therapist to brush bottom teeth with electric toothbrush (all surface areas)
18 Rinses mouth with water
19 Spits water out
20 Opens mouth
21 Accepts toothbrush inserted into mouth
22 Allows therapist to brush top teeth with electric toothbrush (all surface areas)
23 Rinses mouth with water
24 Spits water out
25 Opens mouth
26 Accepts flosser inserted into mouth
27 Allows therapist to floss all bottom teeth
28 Opens mouth
29 Accepts flosser inserted into mouth
30 Allows therapist to floss all top teeth
31 Rinses mouth with water
32 Spits water out
33 Opens mouth
34 Accepts utensils inserted into mouth
35 Allow therapist to examine bottom
36 Opens mouth
37 Accepts utensils inserted into mouth
38 Allow therapist to examine top

and brushing teeth (Set 2), and (c) flossing and examination (Set 3). Measurement was
performed by an observer who was present during sessions but did not interact with the
participants. The observer recorded responses on a data sheet that aligned with each
step in the task analysis.
To be recorded as a correct response, Jason and Luke had to independently
initiate steps in the task analysis within 10–15 s of (a) completing the previous
step and (b) receiving a step-specific verbal instruction (e.g., BOpen your mouth.^)
while not turning head away from or touching the care-provider who implemented
Journal of Developmental and Physical Disabilities (2019) 31:161–170 165

procedures. Failure to meet these criteria was scored as an incorrect response.

Percent independent responding during sessions was calculated by dividing the
number of steps completed independently by the total number of steps (correct +
incorrect) and multiplying by 100.

Interobserver Agreement

During 34% of sessions with Jason and 50% of sessions with Luke, a second individual
conducted measurement simultaneously but independently with the primary observer.
An agreement was scored when both observers recorded an independent response on
the same task analysis steps. Average IOA (agreements/ agreements + disagreements ×
100) was 99.7% for Jason and 100% for Luke.

Procedures and Experimental Design

We implemented baseline and intervention procedures in a changing criterion design

(Kazdin 2011) with both participants.

Baseline One care-provider greeted the participants outside of the simulated dentist’s
office, informed them that it was BTime to see the dentist,^ and then initiated the task
analysis. If the participants responded independently on a step (10–15 s latency), the
care-provider advanced to the next step. When a step was not completed independently,
the care-provider terminated the session. Thus, during baseline sessions the participants
were given the opportunity to complete dental examination-cleaning without
intervention.
The baseline phase for Luke also included additional procedures to encourage
responding after he did not respond independently on any of the task analysis steps
during the initial two sessions. These procedures consisted of the care-provider pre-
senting a gesture prompt (point cue) at each step (sessions 3–4) and presenting a gesture
prompt with accompanying praise for completion at each step (session 5).

Intervention

Intervention I The dental desensitization intervention included three general proce-

dures and is summarized in Table 2. First, graduated exposure was applied by
presenting the participants with different combinations of task analysis steps during
successive sessions. We combined steps based on our judgement of what the partici-
pants had comfortably tolerated during earlier sessions.
Second, positive reinforcement was initially presented to the participants when they
responded independently to exposure steps (10–15 s latency) that were presented
during specific intervention phases. Reinforcers were selected from paired-stimulus
preference assessments preceding the study (Fisher, Piazza, Bowman, Hagopian,
Owens, & Slevin, 1992). Both participants preferred foods consisting of small pieces
of Rice Krispy bars (Luke) and candy (Jason). The care-provider implementing
intervention also delivered response-specific praise with edible reinforcement (e.g.,
BGood, you opened your mouth!^).
166 Journal of Developmental and Physical Disabilities (2019) 31:161–170

Table 2 Intervention phases, exposure steps, and schedules of reinforcement

Participant Intervention phase Exposure steps Post-step delivery of edible

reinforcement

Luke Intervention I-A 1–6 Every step (1–6)

Intervention I-B 1–38 6,8,11,14,17,22,27,30,35,38
Intervention I-C 1–38 6,8,14,22,30,38
Intervention I-D 1–38 8,14,22,30,38
Intervention I-E 1–38 22,38
Intervention I-F 1–38 38
Intervention I-G 1–38 No reinforcement
Jason Intervention I-A 1–8 Every step (1–8)
Intervention I-B 1–9 3,6,9
Intervention I-C 1–10 8,10
Intervention I-D 1–11 11
Intervention I-E 1–14 14
Intervention I-F 1–17 17
Intervention I-G 1–20 20
Intervention I-H 1–26 26
Intervention I-I 1–32 6,8,11,14,17,22,27,32
Intervention I-J 1–32 32
Intervention I-K 1–32 No reinforcement

The third intervention procedure was reinforcement fading which entailed delivering
edible reinforcement to the participants upon a gradually increasing number of inde-
pendent responses, then eliminating edible reinforcement and providing praise approx-
imately half-way through and at the conclusion of sessions. The sequence of reinforce-
ment fading occurred contingent on the participants independently completing expo-
sure steps more rapidly and without interruption.

Probe Assessments The purpose of probe assessments was to determine the

sequence of intervention phases with the participants following preceding exposure
steps. During probe assessments, the care-provider presented Luke and Jason with the
full task analysis but withheld edible reinforcement when they responded independently.
Three probe assessments were conducted with Luke following the first intervention
phase (I-A) and three probe assessments were conducted with Jason following the ninth
intervention phase (I-I).

Results

Figure 1 shows the number of task analysis steps Luke completed independently during
baseline and intervention phases. Across the five baseline sessions, he completed only
one step. During the first intervention phase when he was exposed to steps 1–6, Luke
Journal of Developmental and Physical Disabilities (2019) 31:161–170 167

Intervenon

Probe
Baseline
A B C D E F G
38
37
36
35
34
33
32
31
30
29
28
Number of Steps Completed Independently

27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91
Sessions

Fig. 1 Number of steps Luke completed independently during baseline and intervention phases. Horizontal
lines indicate intervention step criteria

averaged 3 steps per session. The probe assessments revealed that he was able to
complete all of the steps in the task analysis and these steps continued to be presented
during the remaining intervention phases with reinforcement fading. Approximately
4 months following the study, Luke made two successful visits to a dentist’s office and
tolerated tarter removal from his teeth, flossing, and polishing.
Figure 2 shows the number task analysis steps Jason completed independently
during baseline and intervention phases. In baseline, he demonstrated a gradually
decreasing trend, averaging 17 steps per session. During intervention phases A-G,
Jason consistently matched the criterion for exposure steps, with more variability
displayed during intervention phases H-I. The probe assessments revealed that he
was able to complete all of the steps in the task analysis and these steps continued to
be presented during the remaining intervention phases with reinforcement fading.

Discussion

Two students with ASD and dental avoidance learned to tolerate basic tooth cleaning
and examination procedures through graduated exposure, reinforcement, and reinforce-
ment fading. Preceding intervention, both Luke and Jason resisted dental procedures, at
times refusing to sit in a dentist’s chair and follow simple requests such as opening their
mouths. They would sometimes engage in co-occurring behaviors that were disruptive
and physically challenging but these problems were not encountered in the study,
perhaps because intervention allowed them to accommodate to steps in the
examination-cleaning task analysis without using hand-over-hand prompting or similar
procedures that might occasion resistance and non-compliance. Other facets of
168 Journal of Developmental and Physical Disabilities (2019) 31:161–170

Intervenon

Probe
Baseline A B C D E F G H I J K
32
31
30
29
28
27
26
25
24
Number of Steps Completed Independently

23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 161
Sessions

Fig. 2 Number of steps Jason completed independently during baseline and intervention phases. Horizontal
lines indicates intervention step criteria

intervention which may have contributed to their success were having familiar care-
providers implement procedures within a simulated dental setting that was readily
accessible and contained in the natural living environment (Conyers et al. 2004). In
summary, these findings support the results of other dental desensitization programs for
persons with IDD and suggest that relatively low-demand intervention plans can be
applied efficiently and effectively.
The changing criterion design, as illustrated in this study, is well suited to evaluating
desensitization-focused intervention. Notably, the steps comprising a desensitization
hierarchy can be arranged as the performance criteria that produce positive reinforce-
ment. In this regard, Luke was able to tolerate more rapid exposure to the full
desensitization hierarchy whereas more gradual exposure was applied with Jason.
The adjusting criteria with both participants corresponded with the step requirements
and the gradually Bthinned^ schedule of reinforcement that was in effect. They consis-
tently achieved these criteria throughout intervention and upon completion of the study
when in-session reinforcement had been eliminated.
One of the essential procedures included in all previous dental desensitization
research was positive reinforcement of compliance with procedures and absence of
interfering behaviors. We conducted pre-intervention preference assessments with the
participants to identify stimuli that would motivate and reinforce independent comple-
tion of task analysis steps. Of note was the finding that their high-preference choices
were sweet foods that might possibly be contraindicated in a program devoted to dental
care. However, our intervention objective was to rapidly establish tolerance of the
examination-cleaning procedures, then quickly fade and eliminate the foods in favor of
praise alone as the source of reinforcement. Also, the food reinforcers were delivered in
very small pieces during all sessions. Both Luke and Jason progressed successfully
through intervention and foods were successfully eliminated, notwithstanding the valid
Journal of Developmental and Physical Disabilities (2019) 31:161–170 169

concern of identifying and delivering personal preferences as positive reinforcement

within health-oriented intervention plans (Luiselli 2016).
Post-intervention effects with Luke were tested by having him complete two visits to
a dentist’s office. As described, he tolerated tooth-cleaning objects and procedures that
he had not been exposed to in his dental desensitization program. Unfortunately, we
were unable to schedule and evaluate Jason under similar follow-up circumstances.
More evidence is needed showing that positive outcomes from dental avoidance
interventions of the type used in the present study endure months-years later and under
natural conditions (Cuvo et al. 2010; Maguire et al. 1996).
The simulated features of this study mimicked a dentist’s office but did not include
other sensory stimuli such as overhead lamps, suctions sounds, and water/air picks.
Thus, it is unclear how much the simulation component of intervention contributed to
desensitization with Luke and Jason. Another limitation was that the dental procedures
only included basic examination-cleaning and not drilling, taking x-rays, and ortho-
dontic care. These more invasive procedures would likely require additional and
lengthier intervention. Also, the care-providers who implemented procedures with
Jason and Luke were carefully trained but we did not conduct formal assessment of
their intervention integrity.
Based on the results of this study, it appears that children who have ASD and display
dental avoidance can acquire the skills to tolerate basic examination-cleaning proce-
dures by gradually exposing them to response demands, reinforcing their compliance,
and systematically withdrawing reinforcement as a maintenance-facilitating strategy.
Conducting intervention in their typical surroundings and by natural care-providers
may also hasten success that can be later evaluated during conventional oral care
performed by dental professionals. Further study of generalization effects from inter-
vention and social validity assessment of satisfaction and acceptability among children
and care-providers are also worthwhile research objectives.

Compliance with Ethical Standards

Ethical Approval All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained from the parents of both participants included in the study.

Conflict of Interest The authors declare that they have no conflict of interest.

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