Experiences of Dental Care and Dental Anxiety in Adults with Autism Spectrum Disorder

Oral health-care practices and dental assistance management strategies for people with autism spectrum disorder: An integrative literature review

ABSTRACT

Autism spectrum disorder requires a careful approach from professionals and a favorable clinical environment for dental care and assistance. This article aims To perform a literature review about oral health among people with autism spectrum disorder and dental management strategies for this group. An integrative literature review was carried out in three databases, associating the descriptors: (autism or autism spectrum disorder) with (oral health or oral diseases) and (dental care or dental services). After identification and screening steps, 32 articles were included in the study. The most prevalent subjects were oral health conditions, parents’ understanding and practical attitudes about oral health, treatment and management strategies, and the use of technology. The principal barriers to dental care were the scarcity of specialized professionals, unpreparedness in the referral system, poor accessibility of the clinics, and lack of specific care protocols. The world literature on the subject is scarce, and there is still a need for investment and scientific production due to the incidence of autism in the world population and the maintenance of difficulties and barriers in offering quality health care to this group.

Development and evaluation of an individualised dental habituation programme for children with autism spectrum disorder living in Rogaland, Norway

PURPOSE

To develop and evaluate an individualised habituation programme for children with autism spectrum disorder (ASD) to enhance their cooperation during a routine dental examination.

METHODS

In collaboration with school personnel, we developed and evaluated a research-based habituation programme comprising a toolbox with aids (pictures, videos, appliances, social stories) for preparations and gradual exposure to a 10-step dental examination. The habituation programme was subjected to a small-scale evaluation involving 17 children with ASD living in Rogaland, Norway. Changes in cooperation were registered using Frankl behaviour rating scale. Further, school personnel were interviewed using semi-structured interviews, and the data obtained were analysed through content analysis.

RESULTS

Fourteen children (82%) completed the dental examination. Compared to previous accomplishments reported by the caregivers, an increased number of children completed the examination with a mirror and probe and were able to take an X-ray with good compliance following the habituation programme. The registration of cooperation (Frankl score) during each session indicated varying progression rates. Further, changing the dentist did not influence compliance, and most children showed a similar level of cooperation towards the dental examination one year later. Further, school personnel highlighted the need for preparations that could facilitate control and the importance of catering to individual needs.

CONCLUSION

An individualised approach combining preparations and behavioural methods in close collaboration with school personnel can increase cooperation during a dental examination in children with ASD.

Patient-self-reported history of restraint among 17-year-olds: a retrospective study of records by non-specialist dentists in the public dental service in Hordaland, Norway

PURPOSE

The primary purposes were to examine dental records of Norwegian adolescents' with and without self-reported history of restraint for information about oral health (DMFT), total scheduled time in the Public Dental Service (PDS) (dental appointments, cancelled and missed appointments), and reluctant behaviour and/or dental fear and anxiety (DFA). Another purpose was to explore their dental records for information recorded by the dentist concerning the use of restraint.

METHODS

Data on patient-self-reported history of restraint and DFA were collected in a population-based cross-sectional survey of 17-year-olds in the PDS in Hordaland, Norway, 2019. Patients were divided into two groups: self-reported restraint group (N1 = 26) and self-reported non-restraint group (N2 = 200). Data on oral health and dental treatment, total scheduled time of the PDS, reluctant behaviour or DFA, and information on the use of restraint were extracted from the dental records written by non-specialist dentists using a pre-set protocol covering the period from 2002 to 2019.

RESULTS

A total of 206 dental records were analysed. Adolescents with self-reported history of restraint (n1 = 18) had higher DMFT and greater descriptions of reluctant behaviour and/or DFA, and total scheduled time compared with the self-reported non-restraint group (n2 = 188). The use of restraint was recorded in the dental records of one patient from the self-reported restraint group and in two patients from the self-reported non-restraint group.

CONCLUSIONS

The adolescents with self-reported history of restraint had higher DMFT, higher scheduled time attending the PDS, and had more descriptions of reluctant behaviour and/or signs of DFA compared with the self-reported non-restraint group. The patient records contained limited information concerning restraint, and there were significant discrepancies between patient-self-reported history of restraint and the recording of restraint by the dentist in the patients' records.

Sensory-Adapted Dental Environment for the Treatment of Patients with Autism Spectrum Disorder

Purpose: The importance of dental care and oral hygiene is often underestimated in people with autism spectrum disorder (ASD). Comorbidity with dental anxiety is greater in ASD subjects who also show unusual reactions to sensory stimuli. The aim of our study was to assess the efficacy for a sensory-adapted environment and targeted methods in reducing anxiety and positively influencing cooperation in children with ASD during a dental examination or specific treatments. Material and methods: The sample consisted of 50 Italian children with a diagnosis of ASD (36 males and 14 females; aged 9–10 years) presenting with mild intellectual disability (ID) and verbal language skills. The subjects enrolled in the study had at least two decayed teeth and all were treated in two different dental environments: regular dental environment (RDE) and sensory-adapted dental environment (SADE). Results: 20% of the sample was successfully treated in RDE, while 68% of subjects were successfully treated in SADE. Conclusions: Results suggest that a sensory-adapted environment positively affects the therapeutic dental treatment in patients with ASD and reaffirm that sensory dysregulation in children with ASD is a crucial factor influencing the successful outcome of oral care.

The Development of Psycho-educational Module of Dental Management for Primary Caregivers and Teachers of Autism Children: A Qualitative Study in Special Region of Yogyakarta, Indonesia

BACKGROUND: The prevalence of autism increases globally and in Indonesia. Children with autism experience intellectual, behavioral, and anxiety disorders, including fear of dental care. These children often experience difficulty brushing teeth and are reluctant to visit dental care facilities. The poor oral and dental cleanness in children with autism may increase the risk of dental and oral diseases such as periodontal disease and caries. One preventive effort is providing psycho-education to the child and the people surrounding them (parents or caretaker and teacher). Psycho-education modules should be adequate and based on the client’s needs. AIM: The aim of the study was to explore the contents of the psycho-educational module as a guide for primary caregivers and teachers to prevent dental and oral health problems of the child with autism. METHODS: We conducted a qualitative study using focus group discussions (FGD) and in-depth interviews from 12 November to 26 December 2020. This study involved 11 primary caregivers and 14 teachers of the autism-special school in Yogyakarta, Indonesia. The FGD and in-depth interviews were recorded and verbatim transcripted and were analyzed by thematic content analysis. RESULTS: We found three topics required to maintain the dental and oral health of a child with autism, namely: Management of behavior in autistic children, oral-dental treatment, and nutrition management in dental-oral health in autistic children. Available materials used practical and straightforward language. CONCLUSION: The study findings provide an important information as a new approach contained in the module on maintaining oral health to improve the health status of autistic children.

Malocclusion complexity and orthodontic treatment need in children with autism spectrum disorder

OBJECTIVES

This study aimed to investigate the malocclusion complexity and orthodontic treatment need among children with and without autism spectrum disorder (ASD) referred for orthodontic treatment by quantifying the Discrepancy Index (DI) and Index of Orthodontic Treatment Need (IOTN).

MATERIALS AND METHODS

Dental records of 48 ASD and 49 non-ASD consecutive patients aged between 9 and 18 years (median age 13.0 years) referred for orthodontic treatment were reviewed and compared. The Discrepancy Index (DI) was quantified to determine the malocclusion complexity, and the Index of Orthodontic Treatment Need (IOTN), including the Dental Health Component (IOTN-DHC) and Aesthetic Component (IOTN-AC), was quantified to determine the orthodontic treatment need. Statistical analysis included descriptive analysis, Pearson chi-square tests, Fisher's exact test, Mann-Whitney U tests, and several univariate and multivariate regression analyses. The statistical analysis used descriptive analysis, Pearson chi-square test, Fisher's exact test, and multivariate logistic regression.

RESULTS

The results show that both malocclusion complexity (DI, p = 0.0010) and orthodontic treatment need (IOTN-DHC, p = 0.0025; IOTN-AC p = 0.0009) were significantly higher in children with ASD. Furthermore, children with ASD had a higher prevalence of increased overjet (p = .0016) and overbite (p = .031).

CONCLUSIONS

Malocclusion complexity and orthodontic treatment need are statistically significantly higher among children with ASD than children without ASD, independent of age and sex.

CLINICAL RELEVANCE

Children with autism may benefit from visits to a dental specialist (orthodontist) to prevent, to some extent, developing malocclusions from an early age.

Atypically slow processing of faces and non-faces in older autistic adults

Face recognition is a fundamental function that requires holistic processing. Differences in face processing have been consistently identified in autistic children, but it is unknown whether these differences persist across the adult lifespan. Using event-related functional magnetic resonance imaging, we measured holistic face processing with a rapid Mooney faces task in 50 autistic and 49 non-autistic participants (30–74 years). Behavioral tasks included a self-paced version of the same paradigm and a global–local processing task (Navon). Reduced detection rates for faces, but not non-faces, were found in autistic adults, including slower responses on all conditions. Without time constraints, differences in accuracy disappeared between groups, although reaction times in correctly identifying faces remained higher in autistic adults. The functional magnetic resonance imaging results showed lower activation in the left and right superior frontal gyrus in the autism group but no age-related differences. Overall, our findings point toward slower information processing speed rather than a face recognition deficit in autistic adults. This suggests that face-processing differences are not a core feature of autism across the adult lifespan.

UK-based specialist dental professionals' experiences of working with autistic patients

AIMS

Previous research has demonstrated that autistic individuals often experience difficulties accessing dental care, both as a result of autism specific difficulties and practitioners' attitudes towards autism. However, very little research exists that explores dental professionals' experiences of providing care to their autistic patients. The aim of this study was to investigate the strategies UK-based dental professionals' use when working with autistic patients METHODS AND RESULTS: In this study, dental professionals (n = 16) from a variety of specialty roles (special care, paediatrics, orthodontics) were interviewed. We asked participants to talk through, in depth, specific cases they had encountered in their practice, what sorts of accommodations they had provided, and what concerns had arisen during appointments. Thematic analysis was used to analyses the data and revealed four main themes: the unique dental needs associated with being autistic, effective adaptations to practice, the crucial role of the caregiver, and the importance of specialist knowledge CONCLUSION: Recommendations for how dentists can improve the dental experiences of autistic patients can be drawn from the specialist dentists' responses in this study. These include involving autistic patients in decisions about their treatment and being flexible and willing to work with autistic patients and their caregivers.

Dental experiences of a group of autistic adults based in the United Kingdom

AIMS

Previous international research has shown that autistic people have difficulty accessing dental care due to sensory processing, anxiety and communication issues. However, it is not known whether autistic adults in the United Kingdom are experiencing similar dental care barriers. The current study investigated autistic adults' dental experiences in the United Kingdom.

METHODS AND RESULTS

A mixed methods survey was given to self-selecting autistic (n = 37) and non-autistic adults (n = 43) to compare whether autistic individuals had more negative experiences than non-autistic individuals. Closed questions asked about anxiety, patient-practitioner communication, satisfaction and the dental environment. Open questions asked about autism-specific dental challenges, what works well at the dentist, and improving autistic individuals' experiences. Responses were analyzed using thematic analysis. Overall, results demonstrated that autistic adults in the United Kingdom have more negative dental experiences than non-autistic adults. These predominantly related to interactions with dental practitioners, a challenging sensory environment, anxiety, pain, and disclosure. Participants recommended sensory environment adaptations, ways to increase preparedness, longer appointments, and individual accommodations.

CONCLUSION

This study offers best-practice strategies for working with autistic patients and highlights the importance of dentists working with autistic individuals to maximize the quality of care and outcomes for this underserved population.

Parents' satisfaction on dental care of Dutch children with Autism Spectrum Disorder

PURPOSE

To assess if Dutch children with Autism Spectrum Disorder (ASD) regularly visit a dentist and to evaluate parent's satisfaction on the care provided.

METHODS

Parents of ASD children (2-18 years) were invited to fill out a survey. The survey consisted of questions regarding ASD severity, frequency of dental visits, history of dental pain, type of dental practice and parents' satisfaction. Results were analysed using Chi square and Mann-Whitney U tests (α = 5%).

RESULTS

Of the 246 returned questionnaires, 19 were excluded (incomplete or unconfirmed ASD diagnosis). All children visited a dentist at least once and 5% of them had their last visit more than 12 months ago. According to parents, 15% of the children did not receive the needed care when they had toothache and 21% of the parents were unsatisfied with the current dental care provided. No difference was found between satisfied and unsatisfied parents in type of dental practice visited (p > 0.05). The children of unsatisfied parents reported more often pain during the last year (p = 0.013) and had a more severe type of ASD (p = 0.016).

CONCLUSIONS

The majority of Dutch ASD children investigated regularly visit a dentist and 21% of the parents is unsatisfied with the dental care provided.

Psychoeducational intervention to improve oral assessment in people with autism spectrum disorder, BIO-BIO region, Chile

BACKGROUND

To assess the effectiveness of a psychoeducational intervention program designed to facilitate the performance of a series of steps of oral examination in children, adolescents and adults with autism spectrum disorder (ASD), in the Bio-Bio region, Chile.

MATERIAL AND METHODS

A prospective, quasi-experimental study with pre-intervention, post-intervention and maintenance tests was carried out. Behavior was measured using Frankl's scale and the number of steps of a dental examination completed (1-10 steps) was also recorded. Only 104 of the 188 subjects with ASD that agreed to participate in the study met all the inclusion criteria.

RESULTS

82 people with ASD completed the psychoeducational intervention. The mean number of steps achieved pre- and post-intervention was 4.1 and 9.4, resulting in a clinically and statistically significant difference. Regarding behavior, the median in the pre-test was 2 (negative behavior) and in the post-test it increased to 3 (positive behavior), this difference being relevant and statistically significant. A maintenance test one month later on 63 people with ASD found no variations in behavior and in the number of examination steps completed.

CONCLUSIONS

The proposed intervention was effective as an increase of more than 5 in the number of steps of examination completed was achieved. Frankl's behavior rating also increased, from negative to positive, in a group of children, adolescents and adults with ASD.

A cross-sectional study on oral health and dental care in intellectually able adults with autism spectrum disorder

Background

Autism spectrum disorder (ASD) is characterized by impairments in social interaction and communication, restricted patterns of behaviour, and unusual sensory sensitivities. The hypotheses to be tested were that adult patients with ASD have a higher caries prevalence, have more risk factors for caries development, and utilize dental health care to a lesser extent than people recruited from the normal population.

Methods

Forty-seven adults with ASD, (25 men, 22 women, mean age 33 years) and of normal intelligence and 69 age- and sex-matched typical controls completed a dental examination and questionnaires on oral health, dental hygiene, dietary habits and previous contacts with dental care.

Results

Except for increased number of buccal gingival recessions, the oral health was comparable in adults with ASD and the control group. The group with ASD had less snacking, but also less frequent brushing of teeth in the mornings. The stimulated saliva secretion was lower in the ASD group, regardless of medication. Frequencies of dental care contacts were equal in both groups. The most common reason for missing a dental appointment was forgetfulness in the ASD group.

Conclusions

Adults with ASD exhibited more gingival recessions and considerably lower saliva flow compared to healthy controls. Despite equal caries prevalence, the risk for reduced oral health due to decreased salivary flow should be taken into consideration when planning dental care for patients with ASD. Written reminders of dental appointments and written and verbal report on oral health status and oral hygiene instructions are recommended.