Dental anxiety in patients with borderline intellectual functioning and patients with intellectual disabilities

Facilitating oral healthcare for children with disabilities in the Kingdom of Saudi Arabia: a qualitative exploration of the perceptions of parents and professionals

BACKGROUND

Children with disabilities worldwide experience disparities in oral health. Parents and children encounter challenges in accessing quality dental care. Similar challenges are experienced in Saudi Arabia. This study aimed to explore the barriers and facilitators of oral healthcare for children with disabilities in Saudi Arabia.

METHODS

This was an ethnographic study. The sample size was 25 participants, comprising of 12 pediatric dentists and 13 parents of children with disabilities. Data were collected through in-depth interviews, employing a topic guide. A pre-defined analytical framework was developed from the study objectives and framework analysis used to analyse data.

RESULTS

The study identified significant barriers and facilitators to oral healthcare for children with disabilities. Barriers included long travel distances, inadequate clinic facilities, a shortage of specialist pediatric dentists, inefficiencies in referral systems, and financial constraints. Other challenges were related to physical barriers in clinics, cultural norms, and socioeconomic inequalities. Facilitators, though fewer, included personal connections, specialized disability friendly clinics, and the Priority Card Program, albeit with limited effectiveness. Suggestions for improvement highlighted the need for better training for dental professionals, enhanced clinic accessibility, and greater financial support for families.

CONCLUSION

Accessibility of dental care for children with disabilities in Saudi Arabia remains a significant challenge due to systemic barriers and individual-level obstacles. The study underscores the need for policy reforms, enhanced professional training, and the improvement of physical and financial accessibility to dental services. Addressing these issues through comprehensive educational programs and targeted interventions is essential for reducing oral health disparities and improving care for children with disabilities.

Oral Health and Quality of Life in People with Autism Spectrum Disorder

This article delves into the intricate relationship between oral health, quality of life, and behavioral characteristics in individuals with autism spectrum disorder (ASD). Background/Objectives: Autism has been associated with various challenges, and this study seeks to elucidate the impact of ASD on oral health outcomes and overall well-being. The research focuses on assessing overall oral health by evaluating various parameters, such as the condition of lips, tongue, gums and tissues, natural teeth, dentures, oral hygiene, and dental pain in individuals with ASD. Additionally, the study explores the influence of age, sex, and certain variables, like basic daily living skills on oral health practices, aiming to identify potential correlations between these factors and oral health outcomes. Methods: We employed standardized instruments to quantitatively measure and analyze the impact of oral health status on the overall quality of life experienced by individuals with ASD. Results: The study found a statistically significant positive association between oral health, measured by the Oral Health Assessment Tool (OHAT), and quality of life, as indicated by EuroQol 5-Dimensions Youth version (EQ-5D-Y) total scores (β = 0.13045, p = 0.00271). This suggests that better oral health is linked to higher quality of life. When adjusting for age and sex in a multiple linear regression model, the association remained significant but with a slightly reduced effect size (β = 0.10536, p = 0.0167). Age also showed a marginally significant positive association with quality-of-life scores. ANOVA results indicated that participants with advanced oral health status reported significantly higher quality-of-life scores than those with poorer oral health (p = 0.00246). The study also found that intelligence quotient (IQ) does not substantially influence dental health status, while the "Autonomy" subscale of the EQ-5D-Y is positively related to the OHAT. Conclusions: Unhealthy oral conditions significantly impact the overall quality of life in individuals with ASD. Therefore, it is crucial to include regular dental assessments and treatments in therapeutic protocols for patients with ASD.

Implementation of a CBT-based dental anxiety management pathway for patients with learning disabilities

Dental anxiety is a common phenomenon in the general population and may be more prevalent in people with learning disabilities. There is growing interest in the use of cognitive behaviour therapy (CBT) approaches, including within dental anxiety management. However, relatively little is known regarding the application of CBT approaches in dental anxiety management for patients with learning disabilities. This paper outlines details of the implementation of a CBT-based dental anxiety pathway for patients with learning disabilities treated in a special care dental service in England. The pathway is modelled on the utilisation of skills from the dental team (dental nurses and dentists) to deliver a combination of talking sessions, desensitisation and positive affirmation in five distinct stages. Early feedback from service users following implementation of this pathway indicates successful acceptance of dental care with a decreased use of sedative adjuncts.

Lack of assent to dental examination in children with intellectual disabilities: Dentists' practices in Europe and ethical issues

AIM

(1) To determine the repartition of criteria which can be considered as marks of lack of assent by the child with intellectual disabilities from the dentist's point of view and whether that influences the decision to examine the patient or not. (2) To explain the decision of practitioners and determine the ethical implications of these practices.

METHODS

An anonymous and structured questionnaire was distributed online using the scenario of a 9-year-old child with moderate cognitive impairment with eight different oppositional behaviours. The practitioners were asked about their perception of the patient's lack of assent and about their decision to perform the dental examination or not.

RESULTS

The proportion of them who performed a dental examination despite the patient's refusal represented between 13% and 28.8% of the population of respondents.

CONCLUSION

There was an ambivalence among the practitioners who carried out a dental consultation when children were uncooperative. They adopted a teleological point of view. It calls for us to reflect on the ethical principles of autonomy and beneficence.

Autonomic Arousal and Adherence with Dental Appointments

Individuals with developmental disabilities sometimes display avoidance responses such as a lack of cooperation, aggression, and vocal refusal when completing health-care routines such as dental cleanings, physicals, and haircuts. This study evaluated the effects of both graduated exposure and a differential reinforcement procedure on the acquisition, maintenance, and generalization of cooperation with dental routines. In addition, autonomic responses were used as an ancillary measure of distress or comfort and were included in the decision tree of practitioner actions. Procedures were completed in a simulated context of a dental examination. The results of this study may lead to more comprehensive treatment plans that include the use of physiological responses in addition to cooperation with procedures as an indicator that an avoidance response has been extinguished. Assessing autonomic arousal may be a useful addition to the procedures of exposing participants to dental visit routines, to improve adaptation, cooperation, and generalization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00808-x.

Effectiveness of sensory adaptive dental environments to reduce psychophysiology responses of dental anxiety and support positive behaviours in children and young adults with intellectual and developmental disabilities: a systematic review and meta-analyses

BACKGROUND

People with Intellectual and developmental disabilities (IDDs) experience oral health inequality due to myriad of risk factors and complex needs. Sensory processing difficulties, maladaptive behaviours and dental anxiety contribute to difficulties in receiving preventive and routine dental treatments. This study aimed to systematically review the evidence on the effectiveness of sensory adaptive dental environments (SADE) for children and young adults (up to the ages 24 years) with IDD to address cooperation and dental anxiety.

METHODS

This review was reported according to The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. MEDLINE (Ovid), The Cochrane Library, Embase, Google Scholar, Web of Science and OT Seeker were searched using appropriate terms to identify Randomised Control Trails (RCTs) that matched inclusion criteria. Screening was conducted by two reviewers after de-duplication based on titles and abstracts followed by full text retrieval. Quality of the included studies was assessed using Cochrane Risk of Bias (ROB)-2 for crossover trials and data extracted by two reviewers. The details of the interventions and effectiveness were compared and discussed narratively, and comparable outcomes were included to meta-analyses using R software.

RESULTS

A total of 622 articles were identified and five articles met eligibility for inclusion. Three studies used multi-sensory adaptations and one used single sensory adaptation of music. Narrative synthesis showed some evidence of SADE reducing magnitude and duration, although, questionable for reducing the number of maladaptive behaviours. Two studies demonstrated conflicting evidence of the effect of SADE on cooperation. Three studies demonstrated significant positive impact of SADE on psychophysiological outcomes. Despite an overall tendency to favour SADE, no statistically significant difference of maladaptive behaviours was found between SADE and regular dental environment (RDE) (Standardised mean change (SMC) = 0.51; 95% Confidence Interval (CI) -0.20 to 1.22; p = 0.161). SADE was superior to RDE (SMC -0.66; 95% CI -1.01 to -0.30; p =  < 0.001) in reducing psychophysiological responses of dental anxiety.

CONCLUSION

Current evidence suggests that adapting visual, tactile, and auditory aspects of the dental environment in a single or multi-sensory approach demonstrates small positive effects on psychophysiological responses and maladaptive behaviours of dental anxiety for people with IDD.

TRIAL REGISTRATION

The title of this review was registered with PROSPERO (CRD42022322083).

Evaluation of dental anxiety in children with Down's syndrome using dog-assisted therapy: A pilot study

BACKGROUND

Dental anxiety and fear are the major treatment challenges faced by pediatric dentists. Oral hygiene in children with Down's syndrome is highly compromised in comparison to their healthy counterparts. Animal-assisted therapy, through dogs, has been beneficial in alleviating dental fear and anxiety in healthy pediatric population.

AIM

The aim of the study was to assess the impact of dog-assisted therapy (DAT) on children with Down's syndrome undergoing dental examination and fluoride varnish application in dental operatory.

MATERIALS AND METHODS

Twenty children with Down's syndrome between 5 and 12 years of age were selected. Group A (intervention group): DAT was carried out in the dental operatory. Group B (control group): Dental treatment was performed in the absence of a therapy dog in the dental operatory. Anxiety levels were evaluated by recording the pulse rate and revised modified faces version of the Modified Child Dental Anxiety Scale (MCDAS[f]).

STATISTICAL ANALYSIS

The intergroup comparison of pulse rate was done using an unpaired t-test, whereas the variation in intragroup pulse rate was analyzed using the Analysis of Variance test. The anxiety scores were subjected to a paired t-test for intragroup comparison with P < 0.05 considered to be statistically significant.

RESULTS

Reduction in dental anxiety was observed in the intervention group (P < 0.001).

CONCLUSION

DAT can be used as an effective behavior management technique for children with Down's syndrome undergoing dental examination and simple dental procedures in the dental operatory.

A Scoping Review of the Healthcare and Hygiene Literature for Individuals with Intellectual and Developmental Disabilities

Objectives

Previous reviews highlight the similarities in teaching healthcare and hygiene routines to individuals with and without intellectual and developmental disabilities. Additionally, similar interventions are used when interfering behaviors occur. Although these routines are topographically distinct, there are enough similarities to suggest effective procedures for one routine may be used to inform another. This scooping review aims to identify effective teaching and intervention procedures for healthcare and hygiene routines specifically for individuals with intellectual and developmental disabilities. We also evaluated the extent to which functional analyses were conducted; a dimension not included in previous reviews.

Methods

Eligible articles targeted compliance or tolerance within the context of a defined healthcare or hygiene routine as a dependent variable and used an experimental design with a demonstration of experimental control. Articles were identified through PsycINFO, PubMed, and Academic Search Premier databases. Additionally, a hand search of five related journals was conducted. Data were collected on dependent variables, functional analyses, baseline contingencies, teaching procedures, and additional experimental components.

Results

A total of 52 articles met inclusion criteria. Most experiments produced positive outcomes. The findings show all experiments involved a treatment package with multiple components. The most common teaching procedures were graduated exposure and DRA. A lack of functional analyses and social validity was noted.

Conclusions

Component analyses are needed to identify the most effective and efficient procedures. Pyramidal training to teach medical professionals how to provide preventative pyramidal training should be explored.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41252-022-00249-7.

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 methods and use of questionnaires for the diagnosis of dental phobia by Japanese dental practitioners specializing in special needs dentistry and dental anesthesiology: a cross-sectional study

Background

Dental phobia is covered by medical insurance; however, the diagnostic methods are not standardized in Japan. Therefore, the aim of this study was to investigate the methods and use of questionnaires for the diagnosis of dental phobia by Japanese dental practitioners specializing in special needs dentistry and dental anesthesiology.

Methods

We conducted an online survey to obtain information from the members of the Japanese Society for Disability and Oral Health (JSDH, n = 5134) and the Japanese Dental Society of Anesthesiology (JDSA, n = 2759). Response items included gender, qualification, affiliation type, methods of diagnosis and management of dental phobia, use of questionnaire, need to establish standardized diagnostic method for dental phobia, and others. The chi-squared test was used to compare answers between the three groups: JSDH only, JDSA only, and both JSDH and JDSA. Multiple logistic regression analysis was conducted to identify factors associated with the use of an assessment questionnaire.

Results

Data were obtained from 614 practitioners (JSDH only, n = 329; JDSA only, n = 195; both JSDH and JDSA: n = 90, response rate: 7.8% [614/7,893], men: n = 364 [58.5%]). Only 9.7% of practitioners used questionnaires to quantify the level of dental anxiety. The members of both JSDH and JDSA group used questionnaires more frequently than members of the JSDH only (19% and 7.1%, respectively; Bonferroni corrected p < 0.01). Most practitioners (89.1%) diagnosed dental phobia based on patient complaints of fear of treatment. Furthermore, majority of the participants (73.3%) felt the need to establish standardized diagnostic method for “dental phobia.” Multiple logistic regression analysis showed that membership of the JSDH only was negatively related (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.13–0.60), and use of behavioral therapy was positively related (OR 2.34, 95% CI 1.18–4.84) to the use of a questionnaire.

Conclusions

The results of this study showed that the use of questionnaires was very low, patients’ subjective opinions were commonly used to diagnose dental phobia, and a standardized diagnostic criterion was thus needed among practitioners. Therefore, it is necessary to establish diagnostic criteria for dental phobia in line with the Japanese clinical system and to educate dentists about them.

Dental attendance, restoration and extractions in adults with intellectual disabilities compared with the general population: a record linkage study

BACKGROUND

Oral health may be poorer in adults with intellectual disabilities (IDs) who rely on carer support and medications with increased dental risks.

METHODS

Record linkage study of dental outcomes, and associations with anticholinergic (e.g. antipsychotics) and sugar-containing liquid medication, in adults with IDs compared with age-sex-neighbourhood deprivation-matched general population controls.

RESULTS

A total of 2933/4305 (68.1%) with IDs and 7761/12 915 (60.1%) without IDs attended dental care: odds ratio (OR) = 1.42 [1.32, 1.53]; 1359 (31.6%) with IDs versus 5233 (40.5%) without IDs had restorations: OR = 0.68 [0.63, 0.73]; and 567 (13.2%) with IDs versus 2048 (15.9%) without IDs had dental extractions: OR = 0.80 [0.73, 0.89]. Group differences for attendance were greatest in younger ages, and restoration/extractions differences were greatest in older ages. Adults with IDs were more likely prescribed with anticholinergics (2493 (57.9%) vs. 6235 (48.3%): OR = 1.49 [1.39, 1.59]) and sugar-containing liquids (1641 (38.1%) vs. 2315 (17.9%): OR = 2.89 [2.67, 3.12]).

CONCLUSION

Carers support dental appointments, but dentists may be less likely to restore teeth, possibly extracting multiple teeth at individual appointments instead.

Inequalities in treatment planning for children with intellectual disabilities: A questionnaire study of dentists in Europe

BACKGROUND

Children with intellectual disabilities experience major inequality in the field of oral health, including a higher number of extracted teeth. The literature explains this difference in terms of higher levels of dental disease but does not mention the possibility of inequality in the treatment options offered these children.

AIM

The aim is to investigate whether the same treatment options are offered by practitioners to children with and without intellectual disability in equivalent clinical circumstances.

DESIGN

A scenario involving a clinical dental situation was developed, with one varying parameter: the patient described was a child with or without cerebral palsy.

RESULTS

One hundred and thirty-nine dental specialists from France and Europe were recruited. A large number of practitioners (68%) chose the same treatment for both patients, but 32% declared modifying the dental treatment planning in the case of the child with cerebral palsy. The most frequently chosen treatment for the scenario of irreversible pulpitis for the child without disability was conservative endodontic treatment (73%) whereas the most frequently chosen treatment for the child with intellectual disability was tooth extraction (54%).

DISCUSSION

These results are discussed in terms of beneficence, fear of restorative failure, lack of guidelines, practitioner experience and the implications for equity in healthcare.

Pediatric Prevention: Oral Health Care

Children who have a dental home are more likely to receive preventative care, require fewer dental treatments, and are less likely to have dental disease. Many children demonstrate behavior management concerns that may impede families from establishing a dental home for their children. Conceptually, behavior concerns develop through a process of conditioning. Prevention of such problems should focus on providing positive experiences related to dental care. Treatment components to address behavior management concerns include graduated exposure, contingent reinforcement, modeling and prompting, distraction/relaxation, and cognitive behavior therapy. Further support, training, and reimbursement for time required to administer such treatment is needed.

Is there a relation between dental anxiety, fear and general psychological status?

Background

Dental anxiety is a widespread problem in many populations. This problem can be a barrier to dental care and may lead to poor oral health. Dental anxiety may be related to psychological status.

Aims

The aim of the present study was to assess the levels of dental anxiety, dental fear, Beck Depression, and state-trait anxiety according to age, gender and education level in patients at the periodontology clinic in the Diyarbakır Mouth and Dental Health Center.

Study Design

A total of 231 patients (115 males, 116 females) filled out dental fear scale (DFS), dental anxiety scale (DAS), Beck Depression Inventory (BDI), state-trait anxiety inventory-state (STAI-S), and state-trait anxiety inventory–trait (STAI-T) questionnaires, and evaluations of DFS, DAS, BDI, STAI-S, and STAI-T were conducted according to age, gender, and education level.

Results

The mean DFS, DAS, BDI, STAI-T, and STAI –S were 45.64, 9.15, 13.16, 38.90, and 40.18, respectively. There was a significant association among DFS, DAS, BDI, STAI-S, and STAI-T (p < 0.05). These surveys scores were significantly higher in females than males (p < 0.05). The results of this study indicated that gender age and education level have important effects on DFS, DAS, BDI, STAI-S, and STAI-T (p < 0.05).

Conclusion

Dental anxiety and dental fear were found to be related to psychological status (BDI, STAI-S, and STAI-T) over time. There are some patients with unaddressed psychological distress.