Sensory Adaptations to Improve Physiological and Behavioral Distress During Dental Visits in Autistic Children

Abstract

ImportanceAutistic children have poorer oral health and greater oral care challenges, which are often associated with sensory overresponsivity, than neurotypical peers. It is important to identify innovative solutions enabling dentists to successfully perform standard clinic-based procedures for this population.ObjectiveTo determine whether a sensory-adapted dental environment (SADE) reduces physiological and behavioral distress in autistic children undergoing dental cleanings, compared with a regular dental environment (RDE).Design, Setting, and ParticipantsThis randomized crossover trial was conducted at a pediatric dentistry clinic in a large urban children’s hospital between May 2016 and April 2022. Coders were blinded to study condition for physiological but not behavioral measurements. Autistic children aged 6 to 12 years were identified and invited to participate. Interested families were enrolled consecutively; after confirmation of autism diagnosis, children were randomized. Analysis for this per-protocol study were conducted from April to October 2022.InterventionEach child underwent 1 RDE and 1 SADE dental cleaning, administered in randomized and counterbalanced order approximately 6 months apart. SADE included modified visual, auditory, and tactile stimuli.Main Outcomes and MeasuresThe primary outcome was physiological stress, assessed by electrodermal activity. The secondary outcome was behavioral distress measured from video recordings.ResultsAmong 452 families invited to participate, 220 children were enrolled, and 162 children (mean [SD] age, 9.16 [1.99] years; 136 [84.0%] male) with confirmed autism were randomized, with 83 children receiving RDE first and 80 children receiving SADE first. Most children (94 children [58.0%]) had moderate autism severity. Children had significantly lower physiological stress during dental care in SADE compared with RDE (mean difference in skin conductance level, −1.22 [95% CI, −2.17 to −0.27] μS), suggesting decreased sympathetic activity and increased relaxation during SADE dental care. No significant differences were found in nonspecific skin conductance responses (mean difference, −0.30 [95% CI, −0.86 to 0.25] per min). Video-coded frequency and duration of behavioral distress (but not questionnaire) measures were significantly lower in SADE vs RDE (Cohen d = −0.84 to −1.19). Physiological stress was associated with behavioral distress during the dental cleaning (eg, nonspecific skin conductance responses associated with the Frankl Scale: β = −0.29; 95% CI, −0.39 to −0.19); age, IQ, and expressive communication moderated the intervention’s success. No participants withdrew due to adverse effects.Conclusions and RelevanceIn this randomized crossover trial of autistic children, using SADE was safe and efficacious in decreasing physiological and behavioral distress during dental care. This is important because enhancing oral care is critical for autistic children; this intervention may also be beneficial for populations beyond autism.Trial RegistrationClinicalTrials.gov Identifier: NCT02430051

Barriers to Oral Health Care for Autistic Individuals—A Scoping Review

“…General dentists are often required to treat Autistic individuals, but they can lack the training and experience to provide appropriate oral health care including management of sometimes-challenging behavior [ 35 ]. There are a limited number of providers with extensive experience with ASD; dental practitioners need to be calm and understanding, regardless of the behavior of the individual [ 7 , 39 ].…”

“…Adapting to the individualised needs of Autistic patients can include electronic communication systems that prepare the patients for their experience at a dental clinic and address their fear of the dental environment [ 46 , 47 ]; adapting the environment to the sensory needs of Autistic individuals to reduce physical and behavioral stress [ 7 , 11 ]; familiarisation by using visual model techniques [ 48 ]: as well as pre-treatment questionnaires and social stories to enable the Autistic patient and the dental practitioner prepare for their dental visit [ 49 ].…”

“…One aspect of self-care that can be significantly impacted by ASD is oral health. Among various proposed reasons for oral health issues, are factors related to the restrictive repetitive patterns of behavior or atypical responses to sensory input associated with ASD that can increase the difficulty of plaque removal from the smooth and interproximal surfaces of teeth [ 7 , 8 , 9 , 10 , 11 ]. One aspect of atypical responses to sensory input for Autistic individuals is reduced intraoral sensory tolerance which makes it difficult to manage self-care or attend dental assessment and treatment appointments [ 7 , 8 , 9 , 10 , 11 ].…”

“…Among various proposed reasons for oral health issues, are factors related to the restrictive repetitive patterns of behavior or atypical responses to sensory input associated with ASD that can increase the difficulty of plaque removal from the smooth and interproximal surfaces of teeth [ 7 , 8 , 9 , 10 , 11 ]. One aspect of atypical responses to sensory input for Autistic individuals is reduced intraoral sensory tolerance which makes it difficult to manage self-care or attend dental assessment and treatment appointments [ 7 , 8 , 9 , 10 , 11 ]. Parents, carers, and dental practitioners identified difficulties communicating and negotiating behavioral and sensory features of Autistic individuals as a contributor to a higher incidence of unmet dental needs [ 12 , 13 , 14 ].…”

Associations of sensory sensitivity, pain catastrophizing, and alexithymia with dental anxiety

“…Cognitive-behavioral therapy, if effective in treating dental anxiety [53,54], can correct cognitive distortions related to pain catastrophizing. Patients with high sensory sensitivity can be helped with a sensory-adapted dental environment that is considerate to light, sound, smell, and touch, and this is particularly so for children with autism spectrum disorder [55][56][57], and adults with intellectual or developmental disabilities [58]. Relaxation techniques such as breathing and muscle relaxation [59], music therapy, a musicmediated relaxation method [60], or aromatherapy [61] can help in reducing dental anxiety in sensory-sensitive adults.…”