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Behavioral Guidance Approaches to Provide Dental Care for Patients with

Autism Spectrum Disorder: A Review of the Literature

Article in Acta Scientific Dental Scienecs · October 2022

DOI: 10.31080/ASDS.2022.06.1474

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 Acta Scientific Dental Sciences (ISSN: 2581-4893)
Volume 6 Issue 10 October 2022
Literature Review

Behavioral Guidance Approaches to Provide Dental Care for Patients

with Autism Spectrum Disorder: A Review of the Literature

Hanan A Mohamed1* and Eyman M Abdalla2

Received: September 12, 2022
1
Pediatric Dentistry Department, Faculty of Dentistry, Alexandria University,
Alexandria, Egypt Published: September 23, 2022
2
Maastricht University, 6200 MD Maastricht, the Netherlands © All rights are reserved by Hanan A
Mohamed and Eyman M Abdalla.
*Corresponding Author: Hanan A Mohamed, Pediatric Dentistry Department,
Faculty of Dentistry, Alexandria University, Alexandria, Egypt.

DOI: 10.31080/ASDS.2022.06.1474

Abstract
Autism Spectrum Disorder (ASD) is a condition with a specific neuropsychological and sensory profile that complicates dental
procedures. Consequently, most of these patients are treated under general anesthesia or unnecessary sedation. Contemporary and/
or alternative educational and behavioral approaches may facilitate successful dental care for these patients. A literature review
was conducted for relevant information on basic and alternative behavioral approaches for dental care of children with ASD. Basic
educational approaches used for neurotypical children can be applied in the dental setting for ASD children. Examples include
communication guidance, non-verbal communication, Tell-Show-Do (TSD), voice control, positive reinforcement and descriptive
praise, distraction, contingent and non-contingent escape, parental presence/absence, modeling, and desensitization. Additionally,
customized behavior guidance plans can be adapted for children with ASD including sensory adapted dental environment (SADE),
animal assisted intervention (AAI), picture exchange communication systems (PECS), social stories, or video modeling in advance
of the appointment, breaking down dental treatment into sequential components, and modification of the environment to minimize
sensory triggers. A review of the published articles on ASD in dentistry reveals that upon understanding of children with ASD as
individuals and applying contemporary principles of education and behavioral approaches; most of these patients can be provided
with optimal oral health care.

Keywords: Autism; Dental Care; Behavioral Management; Dental Strategies; Dental Techniques; Dental Management

Abbreviations ASD can vary from gifted to severely challenged and they are
ASD: Autism Spectrum Disorder; SADE: Sensory Adapted Dental diagnosed during early childhood, with symptoms becoming
Environment; AAI: Animal Assisted Intervention; PECS: Picture established by age two or three years. ASDs are affecting all racial,
Exchange Communication Systems; DSM: Diagnostic and Statistical ethnic, and socioeconomic groups and are four times more likely to
Manual of Mental Disorders; PDD: Pervasive Developmental occur in boys than girls.
Disorder; ABA: Applied Behavior Analysis; SI: Sensory Integration;
In 2013, the Diagnostic and Statistical Manual of Mental
BGTs: Behavior Guidance Techniques; TSD: Tell-Show-Do; TEACCH:
Disorders-5th edition (DSM-5) was published (Table 1), updating
Treatment and Education of Autistic and Related Communication-
the diagnostic criteria for ASD from the previous 4th edition (DSM-
Handicapped Children; FTB: First-Then Board; AAT: Animal-
IV) [1,2]. In DSM-5, the concept of a “spectrum” ASD diagnosis was
Assisted Therapy
created, combining the DSM-IV’s separate pervasive developmental
disorder (PDD) diagnoses: autistic disorder, Asperger’s disorder,
Introduction
childhood disintegrative disorder, and pervasive developmental
ASDs are a set of lifelong neurodevelopmental disorders
disorder not otherwise specified (PDD-NOS), into one [1]. Rett
defined by a significant impairment in social interaction and
syndrome is no longer included under ASD in DSM-5 as it is
communication with the presence of unusual, repetitive, and
considered a discrete neurological disorder.
stereotyped behaviors. The learning abilities of individuals with

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

72

Changes DSM-IV DSM-5

Location in Manual First diagnosed in infancy Neurodevelopmental disorder
Sub-Criteria Three sub-criteria 2 sub-criteria
Qualitative impairment in social interaction Persistent deficits social communication and social
interaction
Qualitative impairment in communication

Restricted repetitive and stereotyped pattern of Restricted repetitive and stereotyped pattern of
behavior, interests, and activities behavior, interests, and activities

Needed for Triad: 3/3 diagnostic criteria must be met Dyad: 2/2 diagnostic criteria must be met
Diagnosis
Diagnostic Criteria Qualitative impairment in social interaction, manifested Persistent deficits in social communication and
by at least two of the following: social interaction across multiple contexts, as
manifested by the following:
Marked impairment in multiple nonverbal behaviors Deficits in social-emotional reciprocity, (including
such as eye-to-eye gaze, facial expression, and gestures abnormal social approach and failure of reciprocal
regulating social interaction conversation, reduced sharing of interests,
emotions or affect, failure to initiate or respond to
Failure of peer relationship development social interactions)

Lack of spontaneous seeking to share enjoyment, or Deficits in nonverbal communicative behaviors used
interests with other people for social interaction (poorly integrated verbal and
nonverbal communication, eye contact and gesture/
Lack of social or emotional reciprocity body language abnormalities

Qualitative impairments in communication as Deficits in developing, maintain, and understand

manifested by at least one of the following: relationships (including adjusting behavior in vari-
ous social contexts, difficulties in sharing imagina-
Delayed development of spoken language or total lack tive play or in making friends, or lack of interest in
of it. peers)

In individuals with adequate speech, marked Restricted, repetitive patterns of behavior, inter-
impairment in initiating or sustaining a conversation est, or activities, manifested by at least two of the
with others. following:
Stereotyped or repetitive motor movements, use of
Stereotyped and repetitive use of language objects or speech

Lack of varied, spontaneous make-believe play or social Insistence on sameness, inflexible adherence to
imitative play appropriate to developmental level routines, or ritualized patterns of verbal or
nonverbal behavior
Restricted repetitive and stereotyped patterns of
behavior, interests and activities, manifested by at least Highly restricted, fixated interests that are abnormal
one of the following: in intensity of focus
Encompassing preoccupation with one or more
stereotyped patterns of interest that is abnormal either Hyper- or hypo reactivity to sensory input or
in intensity or focus unusual interest in sensory aspects of the
environment
Apparently inflexible adherence to specific,
nonfunctional routines or rituals

Stereotyped and repetitive motor mannerisms

Persistent preoccupation with parts of object

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

73

Age of Onset prior to age 3 years Symptoms must be present in early development
Development period but may not manifest until social demands
exceed limited capacities or may be masked by
learned strategies
Not Better Rett’s disorder or childhood disintegrative disorder Social (pragmatic) communication disorder (SPCD)
Explained by
Sensory Symptoms Not addressed Sensory symptoms are a new criterion introduced in
DSM-5 under the sub-criteria of restricted, repetitive
patterns of behavior, interests, or activities

Table 1: Updated diagnostic criteria for ASD from the previous 4th edition (DSM-IV) to (DSM-5).

Patients with ASD have dental needs like those of any other increase susceptibility and progression of carious lesions. Thus,
patients, however their needs are not usually met. As research due to the various risk factors, patients with autism require special
showed, 8-12% of children with ASD have unmet dental needs management in the dental clinic.
compared to approximately 5% of typically developing peers [3].
Basic and advanced behavioral management techniques used in
The limitation of dental treatment of ASD patients is mainly pediatric dentistry can be applied to patients with ASD, according
attributed to the presence of multiple barriers, including those to the same contraindications considered for children without
met by their typically developing peers, such as uncooperative ASD [5]. However, social communication impairment, which is a
behavior, cost, and lack of insurance [3]. Additionally, ASD patients character of ASD, might alter the usual behavioral approaches that
have atypical behaviors and sensitivities that jeopardize dental focus on positive interactions between patients and dental team
treatment and turn it into one of the most difficult types of health [4].
care received. One of the most challenging barriers is what is known
as “sensory processing disorder”; a disorder affecting the way The Centers for Disease Control and Prevention and National
the nervous system processes and responds to different stimuli Research Council advocate education of ASD children that
received by the five senses. As a result, patients might display focuses upon development of social skills, language, motor skills,
atypical “fight or flight” behaviors or responding aggressively and proper behavior [6]. Among the recommended teaching
when they are overwhelmed by sensations. Fight or flight behavior methodologies that can be adapted in the dental setting are,
appears as an attempt to escape from the distressing stimuli; if applied behavior analysis (ABA), structured teaching, speech and
escape is not possible, the individual will become physically reactive language therapy, social skills instruction, occupational therapy,
to remove himself or herself from the input. Avoidance responses and sensory integration (SI) therapy [7]. ABA therapy works
may escalate to physical aggression ranging from gaze aversion, through analysis of the relationship between a child’s behavior and
physical withdrawal or hiding, pulling away, crying, blocking of the his or her environment. Afterwards, practitioners develop systems
stimuli with arms or hands (i.e., covering ears or eyes), and vocal and structures to reinforce desired behaviors and gradually change
outbursts. More extreme behaviors can include hitting, kicking, undesirable behaviors or responses to stimuli. Contemporary
biting, pushing, tantrums, severe gagging, and vomiting [4,5]. dental behavior management strategies have begun employing the
same learning model used in educational setting of patients with
Moreover, there are a range of individual and environmental ASD.
factors that participate in the elevated risk of poor oral hygiene of
children with autism [5]. Among these factors are limited manual The aim of this review is to provide a thorough search on the
dexterity of children with autism to perform daily brushing and basic and alternative behavioral guidance techniques used for ASD
offering comfort food by parents to calm their children. Most of patients in dental clinic (Table 2).
these foods contain carbohydrates and other sticky foods which

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

74

Basic Behavioral Guidance Alternative Behavioral first attempt for 50% of a group of ASD patients [8] using BGTs
Approaches Guidance Approaches such as, positive reinforcement, TSD, and negative reinforcement.
Nonverbal Communication Sensory Adapted
A survey and chart review were conducted for a group of 43
Environment
patients with ASD [9]. Commonly used communications techniques
Tell-Show-Do Sensory Integration
were used to provide simple dental treatment in the traditional
Voice Control Applied Behavior Analysis
dental setting.
Positive Reinforcement and Visual Pedagogy/ Social
Descriptive Praise Stories, TEACCH, PECS Recent literature reviews reported various dental strategies
Distraction Video Modeling and Virtual and behavior management techniques to manage children with
Reality
ASD such as, positive reinforcement, systematic desensitization
Contingent Escape Animal Assisted Intervention and TSD techniques [4,5,10].
Non-Contingent Escape
Parental Presence/Absence A systematic review published in 2021 identified a range
Systematic Desensitization of strategies in providing dental treatment to children with

Consistency autism, including desensitization, educational strategies (e.g.,

inter-professional collaboration), behavioral strategies and local
Escape Extinction
anesthesia [11]. Examples of the BGTs commonly used to support
Table 2: A summary of basic and alternative behavioral guidance
patients’ behavior
approaches used for ASD patients in dental clinic.
Nonverbal communication
Materials and Methods Describes body language postural changes, hand gestures,
This article summarizes the different strategies used in dental eye contact, physical touch and facial expression as a mean of
clinics to treat patients with ASD. Relevant studies published in communication rather than spoken language [12,13].
the period from 1969 to 2022 were reviewed and the search was
For persons with ASD, nonverbal communication might be the
carried out in the main databases, “PubMed”, “MedLine”, “Science
primary mean of sensing and reading the intentions of others.
Direct”, “Cochrane Database”, and “Google Scholar”. The following
Taking into consideration that autistic individuals exhibit minimal
key words: autism, dental care, behavioral management, dental
use and comprehension of language and inability to follow
strategies, dental techniques, dental management, and autism
multistep instructions. Many of these patients might benefit form
were used.
gestures or visual aids. It is necessary to use a visual support and
Results and Discussion schedule, sensory distraction (redirecting attention), and to rely
on the assistance of the parent/caregiver. However, crossing into
Contemporary/Basic Dental Behavior Management Strategies
personal space of these patient must be measured and initiated
Thorough knowledge of basic behavior guidance techniques at the right moment. On the other hand, ASD patients might not
(BGTs) is crucial to successfully manage children with ASD in the be able to clearly “read” nonverbal communication. Thus, prior to
dental setting. Most notably, patients with ASD display a broad utilizing nonverbal communication guidance, the functional level
variety of abilities and performance and respond inversely to of the ASD patient must be assessed [14].
different management strategies. A tailored dental treatment
approach is recommended rather than generalized treatment TSD
options. TSD is a basic, effective exposure therapy to introduce dental
procedures, instruments, or equipment to a patient. Patients
BGTs were successfully used to provide dental care for children
with ASD benefit tremendously from the TSD as a method of
with ASD. A successful clinical examination was achieved on the

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

75

communication guidance. Modifications to the approach are the reinforced behaviors should increase [13]. Recognition of
required by adding sensory demonstration cues - visual [15], achievement in dental setting creates self-esteem and coping skills
auditory, touch, proprioception, taste/smell - to a simple verbal that will transfer to the next appointments [16]. Descriptive praise
description of a procedure prior to performance of this procedure emphasizes specific cooperative behaviors (e.g., “Thank you for
[12]. sitting still”) rather than a generalized praise (e.g., “Good job”).
Reinforcers could be social, include positive voice modulation, facial
For individuals with limited language, “Foreshadowing” and expression, verbal praise, and appropriate physical demonstrations
“Visualization” are concepts that use positive images, guided of affection. On the other hand, nonsocial reinforcers could be in
relaxation, and measured play to explain to the patient what to the form of tokens and toys.
expect during new procedures. Positive reinforcement throughout
the TSD approach must be constantly provided, regardless of the ASD patient’s cooperation can be greatly enhanced with
patient’s cooperation. This method of behavior guidance might positive reinforcement in the form of constant positive reinforcers,
need to be practiced frequently before the actual procedure; thus, immediate verbal praise after each step of a procedure and a
the positive reinforcement is used to continue to progress in the reward at the end of a dental session.
process [12].
Distraction
The objectives of TSD are to shape the patient’s response Describes diverting a patient’s mental focus or attention from
to dental procedures through desensitization. Demonstrating inappropriate behaviors or procedures to positive thoughts,
materials from the dental office prior to the visit by the parents/ favorable environmental stimuli, or other stimulating sensory
caregiver at home, might introduce the patients to unfamiliar images. Focusing on the positive aspects of something aids in
products used in a familiar environment (the home) [14]. soothing ASD patients. Subsequently, overriding of unpleasant
procedures and redirection of negative behaviors are expected
Voice control
[14]. However, if sensory overload is an issue for the patient, a
Describes gaining the patient’s attention and changing nonstimulant environment will be the ideal setting. All forms of
behavioral direction by alterations of vocal volume, pace, and distractions should be eliminated and counting on a calm “single
intonation [12]. Although persons with ASD may not typically voice” to direct behavior through treatment should be done.
comprehend language, but they can quite sense the mood of others
during interactions. Using a single voice to communicate with the There are several forms of distraction, passive one such as
patient might be beneficial especially if the patient is unable to pleasant sounds and smells, TV/videos, virtual reality eyeglasses
process duplicative input that might cause further disruption. or visual artwork that provide a calming environment. On the other
hand, active distraction such as simply counting aloud, requires the
As suggested by current cultural trends, disciplinary forms patient to focus on a mental task during the negative activity. While
of behavior management strategies like voice control, are losing Imagery distraction by storytelling, is a reminder of an approaching
societal acceptance. Therefore, before using this technique, the rest period that might divert attention.
parent/caregiver must be informed of the use of voice control, to
avoid any confusions during treatment. The aim of the technique Another form of distraction, which is of great value for children
is to rise cooperation and attention while lessening any negative with ASD, is physical sensory distraction, such as using a leaded
behaviors. Although voice control can be used with any ASD patient, x-ray apron, weighted blankets, or stabilization wraps [17,18].
however those with hearing disorders are not good candidate for
this technique [14]. It was reported in various studies that applying firm wrap,
pressure, and/or touch on oversensitive persons might have a
Positive reinforcement and descriptive praise positive calming and soothing effect.
Positive reinforcement is rewarding the desired behavior
with verbal praise, expression, touch or tokens. As a result,

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

76

In the context of self-injurious behaviors, Lindemann [19] etc.”, at the same time provision of care is gradually provided (22).
considered physical restraint and found out that some ASD children Noncontingent escape has been described of benefits for children
can be comforted by using it. with crying, movement, tantrums, and other disruptive behaviors.

A review of literature by Grandin [20] on deep touch pressure Parental presence/absence

applied to patients with ASD and Attention Deficiency and It is utilizing the parent to increase patient psychological
Hyperactive Disorder or ADHD, reported a relaxing and calming comfort and reduce anxiety. Patients with ASD are capable of
effect of deep pressure observed by occupational therapists, enduring procedures that are expected and predictable, however,
whereas Grandin’s light pat can be a tonic to the nervous system. their parents might present many possible emotions or concerns
that might affect interaction with the patients or even their
On mentally challenged patients, the use of various physical
treatment [12]. Thus, the family’s trust should be gained initially
restraints was reviewed and guaranteed safer working setting and
by demonstration of a caring and skillful approach. Parents should
predictable patient’s response [21].
understand and consent to advanced or difficult behavioral
Patients with ASD who are experiencing deficiency in support techniques or refuse the treatment approach. It should
expressive and receptive language, may not be as amenable to the be made clear that the dentist is the primary communicator with
BGTs, including “positive reinforcement, TSD, distraction methods, the child when the parents are present in the clinic. Parents should
non-verbal communication, and voice control” [4]. Therefore, remain silent as much as possible, or should limit discussion
those patients should be recognized as unique individuals taking to non-procedural topics, and resist expression of fear as much
into consideration their diverse abilities and temperaments. In as possible. Anticipating potential obstacles and subsequently
order to successfully support patient’s behavior, adaptation of make the necessary accommodations to facilitate the dental
communicative techniques, moderate office routine, and altered appointment, can be achieved by discussing the procedures ahead
office environment must be considered [12]. of time. A pre-visit questionnaire can be used to enable information
intake; this includes personal medical information, oral habits,
Contingent escape communication, behavior, vision, hearing, sensory sensitivities,
Describes momentary cessation in treatment that is conditional and a thorough record of the patient’s previous medical and dental
upon periods of appropriate behavior [12,22]. In this technique, services [12].
escape will be a rest period from the stimuli or the dental
Systematic desensitization
procedure. The rest period is earned (contingent) upon completion
of a desired behavior, which is an acceptable amount of tolerance Defined as gradual exposure of the patient to a stimulus, feared
of the provided procedure. Giving the patient a short break during object or situation, with the concurrent training and reinforcement
a stressful procedure is used as a positive reinforcement and as an of relaxation [13]. It is a psychological technique that has been
effective method of active distraction as well. The use of contingent successfully applied to modify behavior of anxious patients in
distraction can be beneficial, as the child knows exactly how long the dental office. Patients are gradually exposed to stimuli that
the intervention will take. cause them anxiety over a series of therapy session. Following
habituation and successful approximations, patients will be able to
Noncontingent escape proceed with dental care in a relatively comfortable state.
A technique that provides break from demands or procedures
Learning in short bursts that are delivered incrementally is
in relation to a specified period of time; it is not dependent or
more likely to be retained with ASD children. Thus, treatment
contingent upon patient’s compliance or tolerance. To simplify, the
programs employing desensitization and exposure approaches
break is not “earned”, but the patient’s tolerance of treatment is
have demonstrated marked success with them. Stepwise approach
still rewarded regardless of behavior. For example, counting aloud
was advocated by Swallow [23] through careful and slow repetition
(distraction) as a promise that “we’re going to rest in one, two...
of tasks which enabled dental procedures on even the most severely
affected patients.

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

77

Kopel [24] suggested dividing dental procedures into smaller dental chair, color of bib, flavor of polishing paste, assistant or even
steps with rehearsals at home prior to the dental appointment in the same favorite toy being present during treatment. It is crucial
order to familiarize the child with basic dental instruments and to limit changes of place and routine to extreme necessity [5].
procedures.
Escape extinction
Luscre and Center [25] described desensitization with guided Escape extinction describes the counterintuitive psychological
mastery, symbolic video peer modeling, and reinforcement in approach that in order to overcome fear, an individual must
children with ASD. It was found that severely delayed individuals face that fear. Disruptive behavior of the patient that results in
with ASD can be qualified to participate in upsetting, fear-provoking termination of (escape from) treatment, might reinforce resistive
procedures. behavior and consequently delay the needed care [13].

Unfortunately, dental care therapy often involves aversive and Escape extinction could be done utilizing medical stabilization
intrusive stimuli and always involves violation of personal space. and physical guidance to provide needed treatment. Whereas, it
Therefore, when an aversive stimulus is unavoidably necessary could be simply by saying the word “no” when appropriate, or it
as part of a procedure, positive attention to the patient should may involve repeated verbal or physical prompting to terminate or
be provided immediately after completion of the procedure. redirect escape behavior. Even when a practitioner decided that it
Individualized reinforcements that are meaningful to the patient may not be possible to follow the treatment plan because of the
and encourage desired behaviors could be on a primary level (e.g., behavior, the patient must never perceive that his/her behavior is
food, money) or on a secondary level (e.g., praise, recreation) [5]. the reason of the treatment termination. Treatment termination
should be presented only as the operator’s choice and with positive
Desired behaviors should be reinforced immediately, and the
reinforcement to the patient for his tolerance up to this stage [13].
dentist should consider the use of unconventional reinforcers that
might be used in other aspects of the child’s life, such as a special Alternative behavior strategies
outing or access to movies and video games [4].
Describe strategies for accommodating atypical behaviors of
The amount of time and number of visits required for each children that are not normally considered within the confines of
patient may vary considerably, from 10 minutes to 2 hours per dental daily practice. Review of literature addressed alternative
session, with up to 10-12 visits total. behavioral control strategies used by dentists to treat patients with
ASD (4,10) such as TEACCH (Treatment and Education of Autistic
Although systematic desensitization has a high success and Related Communication-Handicapped Children), ABA, The
rate, the generalizability of the success has been questioned. A Picture Exchange Communication System (PECS), and the Son Rise
patient’s learned skill might be limited to a certain environment program.
and provider. Moreover, severely affected person might be less
amenable to desensitization; it is preferable to be accustomed Sensory adapted dental environment (SADE)
to using these techniques in other areas of their education. Not Individuals with ASD might suffer from sensory processing
to mention the time required for desensitization training which difficulties such as sensory defensiveness, which is a behavioral
makes it uncommon routine in dental setting. overreaction to or extreme avoidance of common sensory
experiences that are often tolerated by others. Depending on the
Consistency received stimuli and the amount of exposure the overreactions
A message that is inconsistently delivered might be confusing would range from mild to severe.
to the patients. Thus, a message should be repeatedly presented
in simple and consistent fashion in order to provide a familiar Multiple sensory impairments can occur in any of the seven
environment for patients with developmental disorders [5]. sensory systems: tactile (touch), vestibular (sense of movement in
Examples of environment familiarity are, the same operatory, relation to gravity), auditory (sound), visual (sight), proprioceptive

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

78

(position of body parts, joints, and muscles as well as the amount of SADE can positively affect dental treatment in children with ASD,
force being used with movement), gustatory (taste), and olfactory thus restating that sensory disorders are critically influencing the
(smell). outcome of oral care.

In most of the cases, the neurological system of these individuals SI

is unable to balance these senses appropriately and filter stimuli, ASD persons with sensory processing impairment are unable
which results in overwhelming amounts of sensory input. Thus, in to integrate information across a variety of contexts (perception,
dental office, creating an atmosphere that will integrate the impact attention, linguistic and semantic). Many theories attempted
of these senses might aid in coping with invasive dental procedures to explain the exact mechanism by which this occurs; however,
[26,27]. all implicate atypical sensory processing as a core element. For
example, individuals with hypo sensation might feel less pain
Based on sensory integration theory and multisensory
and enjoy sensations like strong tastes or intense pressure, on
environments information, environmental changes could be as
the contrary, those with hyper sensation might react intensely to
simple as using quiet and separate room with subdued lighting,
minimal touch, taste, or sound. A combination of these two kinds of
relaxing music, or even running water. These changes have shown
sensory impairments could occur in the same person.
to minimize stimuli and to decrease anxiety [4,26,27]. Additionally,
watching a video to serve as a distractor [18] and the noise Using both remedial and compensatory intervention strategies
reduction in the dental drill as well might efficiently aid in reducing managed by occupational therapy practitioners could help ASD
the anxiety presented by ASD children [27]. children with these difficulties to function better and participate
more fully at home, in school, and in their communities. One of
Other environmental changes that are more elaborate and
the remedial approaches that is designed to improve children’s SI
expensive technologies, like Snoezelen or controlled multisensory
functioning is Ayres Sensory Integration® (ASI) intervention; it
environment, have also been shown to be helpful in reducing anxiety,
involves intensive, individualized occupational therapy sessions
increasing motivation to succeed, and improving co-ordination and
[29]. Another approach is Castillo Morales® Concept which assumes
concentration in individuals with sensory impairments. Snoezelen
that providing intense input for a sense allows the individual to
is used to adapt the lighting, sounds, and textures to the specific
tolerate further stimulation [30]. For example, applying intense
needs of the patient providing a multisensory experience. It has
deep pressure for an individual with hyposensitivity to touch who
been used successfully in hospital-based environment [28].
does not like to have his/her teeth brushed might be beneficial.
Cermak SA [17] conducted a randomized controlled pilot and Firstly, applying firm pressure should be on the extremities; then
feasibility trial examining the impact of SADE to enhance oral care to the forehead, next to the eye area, cheeks, then to the chin area,
for children with ASD. SADE was found feasible to implement and lastly proceed intraorally. Most parents will be aware of what
potential to reduce pain, anxiety, sensory discomfort, behavioral comforts their child, however, the relationship between daily
distress, and physiological stress. oral care and sensory impairments may not be understood by the
parents. Explaining the impact and methods of intervening to the
Another pilot and feasibility study conducted by Cermak., et al. parents will establish long-term and efficient oral health goals.
[26] examined the influence of a SADE to reduce distress, sensory
discomfort, and perception of pain during oral prophylaxis for ABA
children with ASD. A decreased physiological anxiety, lower pain, ABA is an evidence-based treatment that is accepted by the
and sensory discomfort were reported in the SADE condition. American Academy of Pediatrics in the management of ASD. It
implies changing in behavior by analyzing antecedents of behavior
A recent study conducted by Fallea., et al. [27] aimed to and consequences that follow [7].
assess the efficacy of a SADE on reducing anxiety and positively
influencing cooperation in ASD children. It was concluded that a The application of ABA practices in dentistry could be used to
improve the outcome of the conventional BGTs and to consequently

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

79

decrease the need for intrusive procedures, such as restraints and approach to behavior guidance emerged such as visual pedagogy.
sedation. The approach includes the use of books with color photographs,
social stories, or video modeling in combination with traditional
As a component in the desensitization model that is based on BGTs. To increase patient’s comprehension and compliance, it may
task analysis; a specific task (desired behavior) is broken down be beneficial to use the first-then board (FTB) method with visual
into incremental components [7,22]. Each component of this skill schedule. FTB is a fundamental language base that provides step-
would be taught separately, and a child would be rewarded as they by-step visual instructions and ordering of upcoming events. The
master each skill [7,13]. “first” picture is characteristically an activity to build a skill needed
to be performed whereas the “then” activity includes a reward for
Initiation and termination of the stimulus are associated with
the patient that symbolizes an exchange for his/her compliance.
the positive and negative reinforcements respectively. Positive
reinforcer such as rewarding with a toy or praising might enhance In a previous study using visual pedagogy on 14 children with
compliance in the dental chair. On the contrary, negative reinforcer ASD (5-13 years, mean age = 9.3 years), maintaining oral hygiene
such as dental drilling can be managed by keeping the procedure became easier on most parents after 18 months of the study. Thus,
for a predetermined period for example, counting from 1 to 10. it was considered as useful tool to improve oral hygiene of their
Cessation of the procedure should be followed immediately, and children with ASD [31].
the sequence of these events should be repeated as long as needed
to complete the procedure. In a different study, a series of pictures that showed a structured
method and technique of tooth brushing were used in the
One of the behavior methodologies based on ABA is the bathroom, at home and/or at the autism center [32]. A statistically
D-TERMINED Program of Familiarization and Repetitive Tasking significant change in oral hygiene index and plaque index scores
[22]. The program recognizes the most important factor in being were observed.
successful with behavior challenges is to be DETERMINED.
A systematic review was designed and carried out to assess
Three repetition factors are the keys to success in this whether visual pedagogy is an effective tool for oral hygiene
behavior guidance technique, with the use of verbal commands children with ASDs [33].
in a reinforcing manner: (1) Eye contact (reminding the patient to
look at me frequently through the visit) (2) Positional modeling Visual pedagogy is effective in improving and maintaining good
(positioning and holding the legs out straight and hands on the oral health in patients with ASDs, as revealed by improvement of
stomach for a 10 second count) and a (3) Counting framework plaque index and gingival index in all the studies performing this
(verbally and repeatedly count to 10 during a procedure and evaluation. In addition, an increased cooperation of children was
always completing the procedure within this time). seen in almost all studies investigating behavior during dental care.

A retrospective data analysis [22] was performed to compare A blinded, randomized, controlled clinical trial was conducted
the effectiveness of the D-TERMINED Program and BGTs. Based to assess the effectiveness of culturally adapted dental visual aids
on the results of this study, it was found that the D-TERMINED in improving oral hygiene status in children with ASD [33]. Both
program may help the children with ASD to gain the cooperation culturally adapted dental visual aids and regular dental visual
skills needed in dental practice and consequently decrease the aids were effective in improving the oral hygiene status with a
need for operation room referrals. significant improvement in the group that used the culturally
adapted dental visual aids.
Visual pedagogy, social stories-TEACCH and PECS
Visual pedagogy and social stories Visual pedagogy has been used for the development of social
stories; a widely used strategy for ASD children that initially
Based on the ability of children on the ASD to respond better
developed by the special education teacher Carol Gray.
to pictures rather than to words, a variety of non-traditional

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

80

A social story is a description of a situation, social skill, or profile of people with ASD and is reliant on the temporal and
concept that children find challenging in a simplified way, using spatial organization of visual information. The important elements
social cues, perspective, and common responses in a specifically of structured teaching include organization of the physical
defined style and format [5]. environment, predictable sequence of activities, visual schedules,
routines with flexibility, structured work/activity systems, and
This approach is commonly used by parents of ASD; thus, they visually structured activities.
can provide pictures and scenarios of the staff and the environment
that the person will experience. They can be created by the parents In a controlled trial, Ozonoff and Cathcart [36] found that
or by the office, they could be in the form of PowerPoint presentation ASD children who used a TEACCH-based home program for four
or short video clip. Practitioners who seek to create a social story months together with their local day treatment programs improved
for a dental visit should review the guidelines associated with their significantly in terms of cognitive, academic, and prevocational
formulation. These stories are typically short by design and rely on skills.
a ratio of descriptive, perspective and/or affirmative sentences, in
addition to visual cues [5]. Tsang., et al. showed a significant improvement of motor skills
and perception capacity of ASD children subjected to treatment
One of the uses of these stories is in desensitization of the with TEACCH [37].
patients by pre-visit preparation at home together with repeated
dental visits allowing them to see and touch equipment that Callahan., et al. compared between ABA and TEACCH, there was
will be used during their treatment [4]. These stories provide no clear preference for either of the methods found rather than
positive narrative of the upcoming dental experience in addition a significant level of social validity for the components of both
to information regarding home based oral care, preparation of approaches [38].
the child before coming to the dental clinic, and various images
Van Bourgondiën and Coonrod, [39] evaluated the efficacy
and videos. The use of social stories was effective in increasing
of TEACCH 5-session training to facilitate oral evaluation of 10
understanding of dental treatment by parents, and they impacted
different criteria in a group of 34 adults (19-41 years) and 38
positively on the child’s behavior.
children (4-9 years) with ASD. TEACCH was found to be an efficient
TEACCH® method to complete the oral evaluation for adults and children.

TEACCH® technique or Treatment and Education of Autistic Supporting the reliability of the TEACCH program as an
and related Communication-handicapped Children, developed by evidence-based intervention, It was found that the TEACCH-
Mesibov and Schopler [35], is a technique that provides cue cards based training program can be effective in facilitating a full dental
with a precise breakdown of a procedure ahead of time. These visual assessment of children and adults with ASD, with and without
schedules are utilized to make expectations clear and explicit. Most intellectual disability [15].
patients with ASD present behavioral problems and daily stress
because of communication deficits, poor understanding of social (PECS)® and Mobile Application
cues and the difficulty of generalization. These challenges can be Picture Exchange Communication System (PECS)®, based on
enhanced by using the pedagogic strategies based on TEACCH the principles of applied behavior analysis and developed in 1985,
principles through visual organization of the environment by is a unique augmentative and alternative communication (AAC)
visual stimuli or set of signals. It is a technique that helps in keeping system for nonverbal children with ASD. PECS is a behaviorally
the individuals focused, allowing them to be aware of upcoming based pictorial communication system in which children are taught
activities and reducing their level of stress and anxiety. to approach and give a picture of a desired item to a communicative
partner in exchange for that item. In other words, the child initiates
The TEACCH method emphasizes structure, and it was known
a communicative act for an item within a social context [40]. In the
as “structured teaching” which is based on the neuropsychological
PECS program, reinforcement, delay, and generalization across

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

81

trainers and settings are used to shape expressive abilities of Video modeling and virtual reality technology
nonverbal ASD children through six distinct phases. The 6 phases Video modeling is an alternative visual pedagogy-based method
of training are, how to communicate, distance and persistence, for children with ASD due to the growing tendency of electronic
picture discrimination, sentence structure, answering questions, screen media use by them. This approach is an effective strategy
and commenting. for education of children with ASD; the visual nature of video
modeling aids in finding the right frame of reference for behavior
One of the sensory based interventions used with ASD children,
in a context. It might help as well in overcoming the inability to
is mobile application. It is an application designed for smart phones
focus on a stimulus, and in compensating for hypersensitivity to
using a flexible software design. It aims at supporting social skills
stimuli in individuals with ASD [40].
and life skills by encouraging calm, rational behavior in situations
likely to induce high levels of anxiety. ASD population favors visual stimulation, thus video peer
modeling (viewing a procedure on a video) and visual supports are
PECS has been widely used in clinical and social settings for ASD
suggested by literature as an ideal educational tool for them.
children since it is relatively simple to use and teach, inexpensive
and thus, it is expected to be a promising intervention. A survey collected form caregivers of children with ASD
indicated more interest of those children in watching television
A recent study presented an adaptation of ASD patients to
and video than using the computer, in addition to animated
preventive dental procedures in an outpatient environment using
programming preferences versus non-animated. Video modeling
PECS approach without the need for physical restraint [40]. The
approach using an animated character can gain the attention of
Son-Rise Program® principles were followed with a main purpose
ASD children because of their preference for animation together
to seek visual contact with the patients. Although the sample
with the engagement in verbal and physical imitation while
size was small, and a long time was needed for patients to accept
viewing electronic screen media [43].
the method, the results showed an increase in the visual contact
and social interaction with the dentist. The Son Rise program Studies combining both picture cards and video technology
was developed in the 1970’s at the Autism Treatment Center of supported the use of video technology for children with ASD [15].
America, in the United States. The objective of the Son Rise method
is to enhance the functional communication skills and language Orellana., et al. incorporated both pictures and videos in a
development by establishing an individual relationship between an training program to attain a complete dental examination of
adult and a child with ASD, and the adult is requested to prioritize children with ASD [15]. The video presented a model patient
the interests of the child in order to gain his confidence. performing an oral assessment, 81.6% of the children participating
in the program successfully presented cooperative behavior.
In another study aimed at assessing the effect of a PECS-based
tooth-brushing program on gingival health in children with ASD In another study, instructional video clips were implemented to
[41], although PECS was rated as hard, it was useful in improving express requests of children with ASD through the selection and
gingival health in children with ASD. retrieval of picture cards [44].

An interventional parallel arm study [42] consisting of 13- to Literature that compared video modeling based toothbrushing
17-year-old school going adolescent with ASD aimed to evaluate to traditional social stories as an educational intervention for
the effectiveness of two sensory-based interventions namely - children with ASD favored video modeling over social stories [45-
Visual pedagogy using cards and Mobile based application (Brush 47].
Up) on oral health education. There was a statistically significant
Popple., et al. reported a significantly higher efficacy of teaching
reduction in mean plaque and gingival scores seen within both
the correct brushing method and plaque removal in the video
groups, however there was no difference in scores between the
modeling technology compared to the traditional method of
groups. Therefore, both modalities were found to be useful in
printed social story [46].
improving their oral hygiene.

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

82

In consistent with these findings, Mohammadpour., et al. found social stress by acting as a buffer and positive focus of attention.
that video modeling increased self-help skills, such as brushing Recently, neurobiological evidence suggested that ASD children
skills, in ASD children at 1-month and 3-month follow-ups [45]. may perceive greater social reward from animal faces than from
human faces, as indicated by greater activation in brain regions
A recent quasi-randomized controlled trial compared social related to reward and emotional arousal such as the amygdala and
story based toothbrushing education versus video-modeling on putamen.
oral hygiene status of a group of male students aged 7-15 years old
with ASD [47]. It was concluded that tooth-brushing educational A recent systematic literature review was conducted [49]
intervention using video modeling improved oral hygiene status to analyze all empirical research on AAI for ASD published from
more than traditional social stories. 2012 to 2015. increased social interaction was the most reported
outcome across 22 studies. Further research is needed to focus on
Innovations in virtual reality technology contributed to the refining AAI techniques to identify individuals who may not benefit
educational interventions for children with ASD. In one study, in order to move AAI from an enrichment activity to an evidence-
virtual reality simulations were compared to video technology [48], based practice for ASD.
it was found that all strategies used were able to hold the attention
of 6 to 18-year-olds with ASD, taking into considerations that Conclusion
virtual reality simulations gathered more vocalizations compared ASD is one of the most common developmental disorders
to traditional video viewing. encountered in dental practice. Persons with ASD are faced with
access-to-care barriers in part because of the intimidation of the
There could be a probability of anxiety reduction through
health care provider or lack of knowledge about the treatment
mere distraction due to the overall engagement of virtual reality
needs of these persons. Moreover, the daily life, oral health, and the
approach. Therefore, virtual reality programs can be utilized for
ability to receive dental care are affected by the genetic, neurologic,
distraction and relaxation during dental hygiene services and are
sensory, and gastrointestinal nature associated with ASD. Thus,
suitable interventions for children with ASD.
a dental visit can be a main source of stress for all individuals,
AAI including the child, caregiver, and provider.

AAI is integrating animals into therapeutic programming, it Dental healthcare professionals should provide patience,
is comprised of three categories: targeted therapeutic services collaboration, and an individualized approach for patients with
(Animal-Assisted Therapy, AAT), enrichment visits (Animal- autism and their caregivers. Treating the patients and their families
Assisted Activities, AAA), and educational programs (Animal- with respect and dignity, seeing the patient as “different” rather
Assisted Education, AAE). than “disabled”, will reflect positively on the patient and his/her
parents or caregivers.
AAT has been proved to be beneficial in dental environment.
It is defined as a goal-oriented intervention that utilizes a trained It is crucial to recognize that not all persons with a developmental
animal in a healthcare setting to improve interactions or decrease disorder have an intellectual disability. Some individuals with ASD
a patient’s anxiety, pain, or distress [16]. The animal used during require nothing more than the customary practice routine. On
the dental visit, can help break communication barriers and enable the other hand, other individuals may require some assistance,
the patient to establish a safe and comforting relationship, thereby and still others might depend on a third party for decisions or
reducing treatment related stress. AAT is a promising intervention pharmacologic techniques for care.
for ASD children that is highly supported by parents. The presence
of animals may function as a social facilitator to connect individuals However, as discussed above, dental practitioners can learn
with autism to the people around them. Children with autism suffer about the treatment accommodations considered for the ASD
from heightened social anxiety, bully, and rejection by their peers, patients to deliver safe and effective oral health care to these
therefore the presence of an animal may improve some feelings of

Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.
Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disorder: A Review of the Literature

83

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approach and taking the extra time to understand each child as an enhance the practice of dental professionals when treating
individual, the dentist will gain the trust and confidence of the child children with autism: A systematic review”. International
Journal of Applied Dental Sciences 7.1 (2021): 44-52.
and his/her family. Consequently, preparing the child for a lifetime
of positive dental visits. 12. Feigal RJ. “Guiding and managing the child dental patient: a
fresh look at old pedagogy”. Journal of Dental Education 65.12
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Citation: Hanan A Mohamed and Eyman M Abdalla. “Behavioral Guidance Approaches to Provide Dental Care for Patients with Autism Spectrum Disor-
der: A Review of the Literature". Acta Scientific Dental Sciences 6.10 (2022): 71-85.

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