"Mom Let's Go to the Dentist!" Preliminary Feasibility of a Tailored Dental Intervention for Children with Autism Spectrum Disorder in the Italian Public Health Service

Oral care interventions for autistic individuals: A systematic review

LAY ABSTRACT

Oral care-related challenges are well documented in the autistic community; dental care remains one of the most prevalent unmet health needs among autistic individuals. This review examined interventions designed to improve oral health in autistic individuals from children and adult populations. Through a systematic process, 36 studies were identified. These studies focused on improving home-based oral care skills and routines and reducing fear, anxiety, and/or negative behaviors in the dental clinic. Studies incorporated different types of techniques for facilitating oral care practice, including preparatory interventions to support home-based hygiene activities or improve an approaching dental encounter (n = 29), most often using visual aids, and/or strategies to manage behavioral difficulties exhibited in the dental office (n = 17). Some studies used both approaches (n = 10), combining visual aids prior to a visit with behavior management. Using an evidence-based rubric, we reviewed the methodological quality of the studies and found that most were only "adequate" (n = 8) or "weak" (n = 23) in reporting their evidence. This review has two key findings: (1) there is support for preparatory home-based visual interventions to improve toothbrushing and/or ready patients for dental visits; and (2) distraction or sensory-reducing interventions may also improve experiences in the dental clinic. Only one study purposefully recruited autistic adults, and no studies included intervention elements tailored to race/ethnicity, culture, and/or socioeconomic status. This review highlights the need for more studies investigating the impact of oral care-related interventions for autistic individuals of all ages and identifies a gap in interventions for autistic adults and those from minoritized populations.

Management of Procedural Pain and Anxiety in Youth With Autism Spectrum Disorder: A Scoping Review

BACKGROUND

Although there is a body of literature on the implementation of interventions to manage procedural pain and anxiety in youth with autism spectrum disorders (ASD), we found no literature presenting the current state of knowledge on this topic.

OBJECTIVES

To review the state of knowledge on interventions for the management of procedural pain and anxiety in children and adolescents with ASD.

METHOD

A scoping review using PRISMA-ScR was conducted.

DATA SOURCES

PubMed, MEDLINE, all EBM reviews, Embase, APA PsychInfo, EBSCO CINAHL, and ProQuest Dissertations and Theses Global databases were searched. Gray literature was also searched.

ANALYSIS METHOD

Braun and Clarke's (2006) model for thematic analysis in psychology was used to synthesize the search results.

RESULTS

Thirty articles were selected. Analysis of the extracted data revealed four elements of intervention for better management of procedural pain and anxiety in the study population: 1) characteristics of the procedure and the immediate environment; 2) parent-child interactions; 3) health care provider-child interactions; and 4) direct pharmacological and nonpharmacological interventions.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be able to implement appropriate interventions for the management of procedural pain and anxiety in youth with an autism spectrum disorder.

Optimizing Care for Autistic Patients in Health Care Settings: A Scoping Review and Call to Action

OBJECTIVE

We conducted a scoping review of interventions designed to improve the health care experiences of autistic individuals and assessed the methodology and outcomes used to evaluate them.

METHODS

Literature from January 2005 to October 2020 was searched using PubMed, Excerpta Medica dataBASE (EMBASE), Cumulated Index to Nursing and Allied Health Literature (CINAHL), PsycINFO as well as hand searching. Studies included described an intervention for autistic individuals in inpatient or outpatient settings and evaluated the intervention using standardized methodology. Results were exported to Covidence software. Ten reviewers completed abstract screening, full text review, and then systematic data extraction of the remaining articles. Two reviewers evaluated each article at each stage, with a third reviewer arbitrating differences.

RESULTS

A total of 38 studies, including three randomized controlled trials (RCTs) were included. Twenty-six (68%) took place in dental, psychiatric, or procedural settings. Interventions primarily focused on visit preparation and comprehensive care plans or pathways (N = 29, 76%). The most frequent outcome was procedural compliance (N = 15), followed by intervention acceptability (N = 7) and parent satisfaction (N = 6). Two studies involved autistic individuals and caregivers in study design, and no studies assessed racial/ethnic diversity on intervention impact.

CONCLUSIONS

Well-designed evaluations of interventions to support autistic individuals in pediatric health care settings are limited. There is a need to conduct large multi-site intervention implementation studies.

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.

Factors influencing oral health behaviours, access and delivery of dental care for autistic children and adolescents: A mixed-methods systematic review

Background

Autistic children and young people (CYP) experience oral health (OH) inequalities. They are at high risk of dental disease and show significant levels of unmet need in relation to OH and access to dental care.

Aim

This study aimed to gather evidence on the factors that influence OH behaviours, access to and delivery of dental care for autistic CYP.

Design

This was a mixed‐methods narrative systematic review.

Data Sources

Embase, Web of Science, Dentistry & Oral Sciences Source, MEDLINE, Psychinfo, Scopus, CINAHL, SocINDEX and grey literature were the data sources for this study.

Review Methods

A systematic search was conducted for qualitative, quantitative and mixed‐methods research studies from countries with a High Development Index that related to OH behaviours, access to and delivery of dental care for autistic CYP. Results were analysed using narrative synthesis.

Results

From 59 eligible studies, 9 themes were generated: (1) affordability and accessibility; (2) autism‐related factors and cognitive or motor skill differences; (3) the dental environment; (4) managing CYP's behaviour; (5) responding and adapting to the needs of the autistic CYP and their parent/carer; (6) attitude of dental health professionals (DHPs) towards autistic CYP and their parents/carers; (7) knowledge of how to care for and support CYP's OH; (8) empowerment of parents/carers and collaboration with DHPs; and (9) communication and building rapport.

Conclusion

The adoption of healthy OH behaviours and access to dental care by autistic CYP is impacted by a range of factors including those intrinsically related to a diagnosis of autism, for example, communication and those often associated with autism, for example, sensory sensitivities. Access to better OH and dental care can be facilitated by responding to the individual needs of autistic CYP through accommodation, education and adaptation. This necessitates greater awareness and knowledge of autism amongst DHPs and the provision of appropriate services. More methodologically robust intervention studies are needed to identify effective ways to support autistic CYP in achieving good OH and access to dental care.

Patient and Public Contribution

The review protocol was developed with members of the project patient and public involvement group who provided the autistic voice, contributing to the interpretation of the review findings and writing of the manuscript.

Oral Health Preventive Program in Patients with Autism Spectrum Disorder

The aim of the study was to evaluate clinical hygienic parameters, patient collaboration, and dental habits in patients with ASD (autism spectrum disorder) before and after a tailored prevention program. A total of 100 patients (78 males and 22 females, mean age 8 ± 0.7 years old) was recruited, with ages ranging from 7 to 16 years old, and diagnoses of ASD. We evaluated the plaque index (IP), gingival index (IG), the dmft/DMFT, the frequency of tooth brushing, and the frequency of snacks for each patient. Patient behaviour was evaluated with the Frankl scale, and each patient was individually reassessed after five visits from the first one by the same operator. The t test was used to compare the parameters before and after the inclusion in the dedicated dental pathway. From T1 to T2 we found a significant improvement of the IP (p < 0.001), IG (p < 0.001), and the frequency of tooth brushing (p < 0.001). Concerning the frequency of snacks and the parameter dmft/DMFT, the differences in the observed averages were not significant (p > 0.05). The difference in collaboration between T1 and T2 evaluated by the Frankl scale was statistically significant (p < 0.001). It was found that the prevention program allowed a significant improvement in both clinical parameters and patient behaviour. The personalized digital supports can have a key role for success in familiarization and desensitization processes of patients affected by ASD, leading an increase in their collaboration.

Exploring barriers to oral health care experienced by individuals living with autism spectrum disorder

Background

Autism spectrum disorder (ASD) is a developmental disorder that affects behaviour and communication skills. ASD is estimated to affect approximately 1 in 66 Canadians, with symptoms typically arising within the first 3 years of life. Individuals with ASD present with an increased burden of disease and face heightened barriers to oral care.

Objective

This narrative literature review aims to raise awareness of the additional needs that individuals with ASD have when seeking oral care and to identify how barriers to such care may be reduced.

Methods

Twenty-one articles were included in this review, with a wide range of study designs and methodologies. Search terms in PubMed, Education Source, and CINAHL databases included autism spectrum disorder, barriers, dental, dental hygiene, developmental disability, oral health, and unmet needs.

Results and discussion

Key themes that emerged as barriers to care were behavioural challenges, inhibited social and communication skills, parental dependence, clinic environment, and abilities of oral health professionals to treat clients with special care needs.

Conclusion

Current literature reveals that individuals with ASD face numerous barriers when accessing oral care and attempting to achieve adequate oral health, thus contributing to an increased burden of disease. Oral health professionals should aim to improve their understanding of special care populations such as the ASD community and raise awareness among health care professionals to work towards diminishing the barriers to care these populations experience.

Effectiveness of two sensory-based health education methods on oral hygiene of adolescent with autism spectrum disorders: An interventional study

AIM

This study was undertaken with an aim to evaluate the effectiveness of two sensory-based interventions namely - Visual pedagogy and Mobile based application (Brush Up) on oral health education in promoting oral health status among 13-17 year old school going adolescents with Autism Spectrum Disorder (ASD) in Chennai city.

METHODOLOGY

An interventional parallel arm study consisting of 13- to 17-year-old school going adolescent with ASD in Chennai city. Plaque Index (Sillness and Loe, 1964) and gingival index (Loe and Sillness, 1963) were assessed at baseline, 6th week and after 12th week.

RESULTS

A significant difference in plaque (p = < 0.001) and gingival scores (p = < 0.001) were seen among the groups after 6 and 12 weeks post-intervention. There was no statistically significant difference in dental plaque (p = 0.912, 1.023, 0.812) and gingival scores (p = 0.932, 0.264, 0.283) between the groups at all the timelines.

CONCLUSION

In this present study we found that both the visual cards and mobile based application (Brush Up) had significantly reduced the dental plaque and gingival scores; hence both the modalities can be used as an effective tool in educating these children and thus improve their oral hygiene.

Assessment of dental pain in children with intellectual disability using the dental discomfort questionnaire

OBJECTIVE

This study aimed to compare the Dental Discomfort Questionnaire (DDQ) scores in children with and without intellectual disability (ID) and to measure correlation between the total DDQ and the Decayed, Missing, and Filled Teeth (DMFT/dmft) scores, as well as the condition of the tooth causing pain.

METHOD

This cross-sectional study included 81 children with normal intellectual development who attended the Departments of Pediatric Dentistry at two Turkish Universities and 80 children with different levels of intellectual disability who reported dental pain in special education centers. The 12-question DDQ (Turkish version) was applied to the parents of the patients with their consent. The relationship of the DDQ scores with tha of the DMFT/dmft, dental status, and demographic data was evaluated.

RESULTS

When the DDQ scores of children with intellectual disabilities were evaluated, it was found that the majority of the answers given to the questions were statistically similar (p < 0.05) to those of children with normal cognitive level. In the questions in which "pain when eating and brushing teeth" was evaluated, a higher score was obtained, which led to an increase in the total DDQ score (p < 0.001). There was a statistically significant difference between the groups in terms of the distribution of dental conditions (p < 0.001). When compared to the normal cognitive group, patients with mild and severe intellectual disabilities had more deep dentin caries, thoughy, frequent periapical abscess was less common in those groups (p < 0.001 and p = 0.022). There was no statistically significant relationship between DMFTscores.

CONCLUSION

The DDQ was found to be a descriptive, functional, and easy-to-use questionnaire for children with intellectual disabilitiesin terms of detecting the presence of dental pain. No correlation was found between DMFT/dmft, dental status and DDQ scores.

Oral Health and Autism Spectrum Disorders: A Unique Collaboration between Dentistry and Occupational Therapy

Children with autism spectrum disorders (ASD) are at risk for oral health disparities. With the dramatic rise in ASD prevalence to 1 in 54 children, it is likely that an increasing number of dental practitioners will encounter or be asked to treat children with ASD. This paper reviews explanations related to the increasing prevalence of ASD, provides reasons why children with ASD are at increased risk for poor oral health, and discusses unique interprofessional collaborations between dental practitioners and occupational therapists. Occupational therapists and dentists can work together to plan modifications to the dental environment or adapt dental protocols to reduce some of the barriers encountered by those with ASD, provide desensitization strategies before the clinic visit, or help a child with emotional regulation during clinical treatments.

The Challenging Heterogeneity of Autism: Editorial for Brain Sciences Special Issue "Advances in Autism Research"

My personal experience as Guest Editor of the Special Issue (SI) entitled "Advances in Autism Research" began with a nice correspondence with Andrew Meltzoff, from the University of Washington, Seattle (WA, USA), which, in hindsight, I consider as a good omen for the success of this Special Issue: "Dear Antonio… [...].