The number of children and adults diagnosed with sensory processing disorder (SPD) and autism spectrum disorder is climbing each day. It is an issue that can span the lifetime of a patient, and a patient of any age and with any diagnosis can have sensory processing issues. It is the clinician's responsibility to understand and know best how to deal with the fears and anxieties of these patients so even the most routine dental care can be suited to their needs. However, many clinicians have not had a chance to learn about the special needs of these patients. This course will assist dental professionals to develop an appreciation for SPD and the delivery of dental care from the point of view of these patients.
This course is designed for dental professionals involved in the care of patients with sensory processing disorder.
NetCE is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 10/1/2015 to 9/30/2021. Provider ID 217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405.
NetCE designates this activity for 2 continuing education credits. AGD Subject Code 436. This course meets the Dental Board of California's requirements for 2 unit(s) of continuing education. Dental Board of California course #02-3841-16157.
The purpose of this course is to improve the quality of care administered to patients with sensory processing disorder (SPD) by providing dental professionals with information about SPD and health care from the point of view of the patient with SPD.
Upon completion of this course, you should be able to:
- Describe the various components of the sensory system.
- Identify disorder categories within the SPD group.
- Discuss best practices for clinicians when caring for a patient diagnosed with SPD.
Polly Warring, MSPT, has worked in the physical therapy field since 1992. She began as a physical therapy tech in a variety of settings, including outpatient, acute care, skilled nursing, and specialized programs for children with ADHD. She received a Bachelor of Science Degree in Biomedical Science from Texas A&M University in 1990 and graduated with a Master’s of Science Degree in Physical Therapy from Texas Woman’s University in Houston in 1997. While there, she was part of the research team that published the abstract “Quantification of EMG Activity from Five Muscles in Comparison of Four Methods of Rising from Sitting.” She has worked primarily in the adult orthopedic outpatient field since the late 1990s. Mrs. Warring is currently a freelance medical writer residing in Texas with her husband and their six children.
Contributing faculty, Polly Warring, MSPT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
William E. Frey, DDS, MS, FICD
The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
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#56670: Sensory Processing Disorder: Impact on Care
The number of children and adults diagnosed with sensory processing disorder (SPD) and autism spectrum disorder is climbing each day. It is an issue that can span the lifetime of a patient, and a patient of any age and with any diagnosis can have sensory processing issues [1,2]. It is the clinician's responsibility to understand and know best how to deal with the fears and anxieties these patients experience so even the most routine health care can be suited to their needs [3,4]. However, many clinicians have not had a chance to learn about the special needs of these patients [5,6]. This course will assist healthcare providers to develop an appreciation for SPD and to deliver health care to these patients in a sympathetic and effective way.
The clinician's job is to meet the needs of the patient while also working to improve the patient's health. The patient with SPD can often present a difficult clinical situation because of their specific deficits. This may be compounded if clinicians do not understand the underlying needs of someone with this diagnosis.
The senses are used to gather information about the environment and the internal body, and most people are aware of the five main senses: visual (sight), olfactory (smell), gustatory (taste), auditory (hearing), and tactile (touch). There are also three more senses that are not generally known: vestibular, proprioception, and interoception. All eight of these senses are very important, and disruption can cause many issues for the person involved. When all of the senses are working together at an optimal level, an individual has a reliable picture of the environment and their internal status. Patients for whom any one of these systems is not processing stimuli correctly have a different experience than those around them and lives in a world in which they cannot trust their own body.
The visual processing system consists of the eyes gathering information from the environment. This sense assists with balance and is useful for activities of daily living, socializing, and sports. A person who has a faulty visual system might have difficulty following directions involving visual discrimination (e.g., distinguishing one medication from another), interpreting body language (leading to decreased social skills), or following written directions for a home plan. Bright lights and bright colors can agitate patients with visual issues, and moving about in an unfamiliar office may cause anxiety.
The olfactory system is one of the first sensory systems to develop in utero . Many patients with sensory processing disorder have issues with the olfactory system. This can affect eating behaviors, as food often has an offensive smell to them. It can also affect the patient socially because they will avoid going anywhere with an offensive or intense smell or interacting with individuals with a strong smell, even if that smell is cologne or perfume. Most clinics, dental facilities, and hospitals have smells that are a problem for patients with olfactory processing problems.
The gustatory sense provides information about the taste of foods and liquids. A disrupted gustatory system may cause severe feeding issues. Many patients with SPD are "picky" eaters for a number of reasons, one of which might be a gustatory system disruption. When sensory issues are worked on, feeding issues often improve.
The auditory system processes and interprets information that is heard. This includes the skill of auditory discrimination—trying to determine if the sound is closer to the right or left ear, loud or soft, and the quality of the sound. In addition, one part of the cochlea is associated with the vestibular system . A patient with auditory dysfunction might not have impaired hearing, but the quality of the sound could be such that the speaker sounds as if he or she is mumbling or speaking nonsense sounds. This can lead to difficulty understanding instructions or requests.
Hyperacusis occurs when a patient's auditory system is too sensitive, causing pain when a louder noise is noted (e.g., a fire truck goes by on the street). In the clinic, louder medical instruments may bother a person with a sensitive auditory system.
A significant problem associated with auditory discrimination is difficulty following verbal directions. This occurs due to confusion over similar-sounding words (e.g., book and look). The patient might also have a difficult time focusing when background noises are present or become overstimulated when there is too much background noise . This difficulty with communication can lead to frustration for both the clinician and the patient.
Disruptions in the tactile system are common in people with SPD. The tactile system uses information gathered from the largest sensory organ—the skin—to establish a perception of one's environment. The skin is a constant source of information, and it helps determine the quality of objects in the external environment . The skin receives information about pressure, texture, temperature, and pain. There are two subsystems of the tactile system: the protective system and the discriminatory system.
The protective system facilitates a response if a stimulus is perceived as harmful. In patients with SPD, nonharmful things such as coarse fabric, clothing tags, and sock seams can trigger a protective reaction; this is called tactile defensiveness. Pain can feel unusually intense . In the healthcare setting, this can translate to a patient having difficulty wearing and remaining comfortable in medical gowns, defensiveness with oral work, or anxiety with blood pressure cuffs. When this sensitivity is to items being introduced into the mouth, it is called oral defensiveness.
The second subsystem is the discriminatory system, which helps people determine the quality of the object they are touching. This system helps categorize things as hard or soft or smooth or rough. Dysfunction in this area can cause difficulties with such daily fine motor activities as buttoning a coat and handwriting. These persons might avoid certain textures of food, clothing, and surfaces . Poor tactile discrimination is often a focus for sensory therapy.
Difficulty with social situations can also arise with tactile issues. People with tactile defensiveness may be too sensitive or not sensitive enough to touch. This can translate to shying away from a gentle touch or hug or not knowing when a push is too hard. In the healthcare setting, these patients may appear uncomfortable or shy away from the touch involved in a routine exam. This might offend or confuse some clinicians if they are not aware of the patient's sensory issues. Patients who are under-responsive to touch may not be aware that the clinician is palpating for pain, which can result in skewed results due to lack of patient report.
The vestibular system senses the position of the head in space (i.e., special orientation), including direction and speed of head movement. This system involves the structures of the inner ear in conjunction with vision and the auditory system. Difficulty in the vestibular system results in low muscle tone, poor balance, and improper reactions to movements . Poor coordination and stiff or flaccid muscle tone usually convey a faulty vestibular and proprioceptive system, indicating that the cerebellum is relaying incorrectly; these are red flags for SPD . There is an anatomical association between the vestibular and auditory systems, and it is often found that a specific type of vestibular stimulation combined with auditory input results in an improved ability to communicate .
The vestibular system can be disrupted in several ways . Gravitational insecurity causes a person to become very uncomfortable with changes in movement. They can become fearful of movements like climbing, jumping, leaning back, riding in a car, and falling. Over-responsiveness to movement can result in nausea and dizziness during or after movement. Disruption of the vestibular system can cause discriminative issues due to an inability to orient one's position in space. On the other end of the spectrum is an under-responsive system. This becomes apparent when a person is unaware of movements (e.g., rocking). Disturbances can also manifest as a need for more than the usual amount of movement. These patients may excessively run, fidget, spin, and continually re-adjust in order to satisfy their system. Vestibular issues are often very apparent in children with SPD because much of play relies on an intact vestibular system .
The proprioceptive system is a very large system that orients an individual to the position of his or her body parts by detecting changes in the length of muscles and the position of joints. Most proprioception is done without conscious awareness. Difficulty in this area can cause problems in many daily activities, such as handwriting, fine motor and gross motor activities, and sports. Poor body awareness can result in clumsiness, difficulties with posture, and using too much or too little pressure for a task . It may also result in sensory-seeking behaviors, such as crashing or excessive roughness .
Neural systems around the internal organs form the interoceptive system. These nerves detect and transmit information about internal regulation responses, such as thirst, waste elimination, and fullness. In a very young child, difficulty with interoception can lead to delayed toilet training success. Issues with interoception may result in a child constantly reporting headache, stomachache, or other pain, which could result in stigma or confused diagnosis .
As discussed, the sensory system relies on a continuous feedback loop of information from various senses to regulate and process sensory information in order to function. All individuals have different levels of sensory organization and tolerance .
After the senses receive information from the environment, this information must be processed in order for the body to react appropriately. This is the stage at which problems arise for patients with SPD. Often, the messages received by receptors in the sensing areas are misinterpreted by the brain. This misinterpretation results in the wrong messages being relayed/interpreted, and everyday routines and activities become agonizing struggles to complete. Messages that are usually ignored by the brain (e.g., a shirt tag resting on the skin) suddenly become "high alert" messages of pain and discomfort that cannot be ignored. The patient's system must interpret messages from the senses based on this overload/deficit of information. Information from all of the senses is combined, which is difficult when he or she does not have the correct information from the beginning. An automatic response is then made based on missing or incomplete information, and impulses are sent to muscles and limbs to carry out the response. Functioning proprioception is required to know what the limbs are doing even before the new order to respond is put out by the system. If a patient's senses perceive misinformation, he or she must interpret and respond to that misinformation and then rely on body parts that are not responding correctly to carry out a response in the best way possible . It is an accident waiting to happen and can be nerve wracking in even the simplest of situations. Because those with SPD gather and process information differently than people with intact sensory systems, clinician-patient communication can be difficult .
Patients with SPD often experience disruption of many senses, though not all disruptions manifest in the same way. There may be two systems that are over-responsive and two systems that are under-responsive. A common combination is an over-responsivity to touch and sound but a craving for movement and proprioception .
The patient with SPD is often unable to trust much of the information received from the senses. Because of this, they can easily feel off balance if put in new positions (e.g., tilted dental chairs), be clumsy with new movements (e.g., learning to use an inhaler), and be unable to distinguish normal body reactions from illness (e.g., stomach pain from worry).
SPD is commonly divided into three main categories: sensory modulation disorder (SMD), sensory discrimination disorder (SDD), and sensory-based motor disorder (SBMD) . Each disorder has unique characteristics and requires different approaches to manage symptoms.
SMD is characterized by a difficulty regulating sensory stimuli. Patients may be over-responsive, meaning they have the tendency to respond too much, too soon, or for too long to sensory stimuli most people find tolerable . These patients are bothered by usually tolerable stimuli (e.g., the seams in a shirt).
Sensory under-responsive involves a delay or muted response to environmental cues. These patients seem to require more stimuli to feel their environment . This can also manifest as an unawareness of internal cues, such as fatigue or illness. Sensory-craving patients crave and constantly seek sensory stimulation, and the stimuli may not register correctly when it does occur. These patients may appear hyperactive (e.g., continuously jumping while waiting for an appointment) or may talk very loudly to create auditory stimulation.
Patients with SDD have difficulty interpreting subtle qualities of objects, places, people, or the environment. This can affect any of the senses alone or in combination (i.e., auditory DD, visual DD, gustatory DD, olfactory DD, tactile DD, vestibular DD, proprioceptive DD, or interoceptive DD) . For the patient with SDD, interpreting ordinary demands and responding appropriately may require enormous effort .
SBMD involves difficulty with balance, motor coordination, and the performance of skilled, not-habitual and/or habitual motor tasks. Under this category are two subtypes: postural disorder and dyspraxia .
With postural disorder, patients have difficulty maintaining the optimal posture. Posture is important because it is the base from which all of our upper and lower limbs anchor their movements away from the body. Poor or weak postural muscles result in difficulty with scapular stabilization, which leads to difficulty with such milestones as handwriting and strength movements involving the legs. A weak core can have many implications for individuals with SBMD as they age.
Dyspraxia is a type of SBMD and involves difficulty thinking of, planning, and/or executing skilled movements, especially novel movement patterns. These individuals are often seen as clumsy and awkward, as they have problems with gross and fine motor activities. Early physical and occupational therapy can help immensely.
Clinicians treating patients with SPD can take certain steps to ensure a better healthcare experience. It may seem as if these patients are in a different world, are over-reacting to normal procedures, or are ignoring questions or conversations. However, reality for these patients is very different . Taking steps to understand and adjust procedures can facilitate the best possible care.
One of the most important issues to be aware of when working with patients with SPD is that the condition produces significant anxiety. These are not typical nervous patients—they are dealing with a dysfunctional sensory system in an unfamiliar environment. As a clinician, it is important to work with patients to ensure they understand what will be involved in the visit. Provide structure and feedback to help patients understand their environment; patience and communication are paramount. The medical or dental office should be a safe place .
Going to an unfamiliar place, like a medical office, can be an onslaught to the senses for individuals with SPD. To these patients, it may feel as if they are being attacked on all sides, even before they see the clinician. Their system can be on high alert for danger or on such low alert that it is difficult to communicate.
Before a patient arrives at a clinician's office, he or she has often experienced a day's worth of sensory distress. The patient with SPD will see the waiting room in a different way than the typical patient. Coarse fabric on a chair can be an issue, as can temperature, the size of the waiting area, and the number of other people waiting. The patient is also often nervous about the visit, not knowing what to expect. A long wait in an uncomfortable waiting room with no distractions can make anxiety increase before the visit begins. Clinicians should spend time in their own waiting rooms, seeing it through the eyes of a patient with SPD to help address any issues that might be of concern.
The average treatment room is often problematic as well. If a gown is used, the material might be uncomfortable. Exposed skin can make patients overly sensitive or cause them to shut down. Treatment tables or chairs are normally cold and hard, and the instruments used are new and possibly frightening to the patient. Individuals may report pain out of proportion to that expected.
Involving patients with SPD in their care and explaining all procedures fully are the cornerstones of ensuring a positive experience. Patients may hold instruments or examine tools during or prior to procedures. For example, anxious patients with sensory issues may "help" with teeth cleanings by putting their hand on the instrument or they may be allowed to squirt the water from a dental handpiece before a cleaning to help relieve anxiety about the strange objects.
Distraction is also an important tool. If a young patient will receive a reward at the end of the visit, he or she can be asked to pick it out first. Deep pressure often calms a patient with sensory issues, and a patient in the dental office might prefer to keep the weighted X-ray shield apron on during the visit to help calm the sensory system. Of course, it is important to consult with the patient and/or parent to determine if it would help.
Lights that shine in the eyes can be disarming and even painful to those with a sensitive visual system. If sunglasses and headphones are appropriate, they can help to shade sensitive eyes and ears and distract from the medical or dental work.
When a blood pressure cuff is being used, the squeezing sensation can be very alarming to someone with tactile defensiveness. Telling the patient what will happen with the cuff and giving a countdown until the time it will end will help decrease anxiety.
There are also a few key things that clinicians should avoid when dealing with patients with SPD. If the patient is a child, it is important not to exclude the parent. The parent can serve as a translator and filter for the child, and in some cases, patient report can come from the parent. Some medical offices prefer to take patients back without the parent, but this is not helpful for patients with SPD unless the visit is for occupational or physical therapy. Instead, parents should be considered part of the healthcare team. Older patients should be acknowledged as being their own expert, with the knowledge of necessary steps to be more comfortable.
Sudden movements should also be avoided whenever possible. Patients with SPD operate better with an announced or visual schedule from which they can work. Keeping patients advised on the next two or three steps that will occur in the visit will help decrease anxiety. Letting them know when the visit will be over is also good practice.
Some clinicians will downplay patients' fears and dismiss them as unnecessary, but this can add to anxiety. It is best to listen to the patient and validate his or her fears and pain while also explaining the purpose of the procedure at the appropriate cognitive level. Talk through motor activities using directional and spatial terms .
Clinicians should stay informed of the advances in SPD and act as advocates for these patients. If a practice has a large number of patients with symptoms of SPD, continuing education may be beneficial. Some patients may show signs of SPD, and if a diagnosis has not been made, it may be necessary to start a conversation with him or her or a parent. Participation in physical and occupational therapy early allows for advances before long-term learning disabilities begin to develop.
For the patient with SPD, a regular visit to a healthcare provider can be difficult and sometimes terrifying. For clinicians caring for patients with SPD, it can be confusing to understand and accommodate their unique fears and anxieties. This course has explored the various aspects of sensory processing issues and how they affect the patient, with the goal of allowing healthcare professionals to see through the patient's eyes to identify potential triggers of fear or anxiety during a typical office visit. Through collaboration and understanding, patients with SPD can be accommodated, ensuring that they have access to the best possible care with as little anxiety as possible.
The following list of resources is intended to serve as an introduction to those available and is not exhaustive.
No Longer A Secret: Unique Common Sense Strategies for Children with Sensory or Motor Challenges by Doreit Bialer, MA, OTR/L, and Lucy Jane Miller, PHD, OTR
The Everything Parent's Guide to Sensory Integration Disorder by Terri Mauro
The Out-of-Sync Child Has Fun by Carol Stock Kranowitz, MA
The Sensory Processing Disorder Answer Book by Teri Delaney, MS, OTR/L
Too Loud, Too Bright, Too Fast, Too Tight by Sharon Heller, PhD
1. Heller S. Too Loud, Too Bright, Too Fast, Too Tight. New York, NY: Harper Collins Publishers; 2002.
2. Pfeiffer B, Kinnealey M. Treatment of sensory defensiveness in adults. Occup Ther Int. 2003;10(3):175-184.
3. Kinnealey M. Princess or tyrant: a case report of a child with sensory defensiveness. Occup Ther Int. 1998;5(4):293-303.
4. Cosbey J, Johnston SS, Dunn L, Bauman M. Playground behaviors of children with and without sensory processing disorders.OTJR (Thorofare N J). 2012;32(2):39-47.
5. Byrne MW. Sensory processing disorder: any of a nurse practitioner's business? J Am Acad of Nurse Pract. 2009;21(6):314-321.
7. Bialer DS, Miller LJ. No Longer A Secret: Unique Common Sense Strategies for Children with Sensory or Motor Challenges. Arlington, VA: Sensory World; 2011.
8. McMahan S. Sensory Integration for the Physical Therapist. Lecture presented at: Texas Woman's University; 2011; Houston, TX.
9. Mauro T, Cermak SA. The Everything Parent's Guide to Sensory Integration Disorder. Avon, MA: F+W Publications; 2006.
10. Miller L, Cermak S, Lane S, Anzalone M, Koomar J. Subtypes of SPD. Available at http://www.spdfoundation.net/subtypes.html. Last accessed April 4, 2014.
11. Sensory Therapies and Research Center. What is SPD? Available at http://spdstar.org/what-is-spd. Last accessed April 4, 2014.
1. Cincinnati Children's Hospital Medical Center. Best Evidence Statement (BESt): Use of a Weighted or Pressure Device to Modify Behavior in Children with a Sensory Processing Disorder. Cincinnati, OH: Cincinnati Children's Hospital Medical Center; 2012. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=36086. Last accessed April 7, 2014.
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