AlBhaisi et al.

BMC Oral Health (2022) 22:162

https://doi.org/10.1186/s12903-022-02200-7

RESEARCH Open Access

Effectiveness of psychological techniques

in dental management for children with autism
spectrum disorder: a systematic literature
review
Ismail Nabil AlBhaisi1, Marisa Shanthini Thomas Santha Kumar2, Anissha Engapuram2, Zaleha Shafiei2,
Ahmad Shuhud Irfani Zakaria3, Shahida Mohd‑Said1* and Colman McGrath4

Abstract
Background: A rise in the reported numbers of children with Autism Spectrum Disorder (ASD) highlights the need
for dental practitioners to be more familiar with the treatment approaches for these special needs children to ensure
comfortable, well-accepted and efficient management while in dental office.
Aim: This paper aimed to acquire a deeper understanding of some of the innovative and best approaches to manag‑
ing children with ASD in dental settings.
Design: A systematic literature search was performed in PubMed, Scopus, Web of Science, Cochrane databases, and
grey literature based on the PRISMA 2020 statement, using main keywords such as: ‘management’, ‘dental’, ‘children’,
and ‘Autism Spectrum Disorder’. Original full-text papers including randomised controlled trials (RCT) and all other
designs of non-randomised controlled studies (NRS) reporting relevant intervention studies in English were included
without any publication time limit. The quality of the evidence found eligible for the review were then assessed using
the ROB-2 and ROBINS-I tools. Subsequently, the details of management interventions and impact of treatment
approaches were compared and discussed.
Results: Out of the 204 articles found, 109 unrelated articles were excluded during the initial screening. The full
papers of remaining 28 were retrieved and only 15 (7%) articles were eligible to be reviewed; eight RCTs with ‘some
concerns’ and ‘high risk’ categories particularly concerning their randomisation design, and seven NSRs with ‘serious’ to
‘critical’ bias largely due to confounding factors.
Conclusion: Our review found inconclusive evidence on the strength of recent psychological and non-pharma‑
cological approaches used to manage children with ASD in dental settings. Small sample size and lack of a control
group in certain studies affected the strength of evidence and credibility of the findings. Nevertheless, this review
shared informative details on some innovative approaches for better understanding of the management of children
with ASD for dental professionals.

*Correspondence: [email protected]
1
Department of Restorative Dentistry, Faculty of Dentistry, Universiti
Kebangsaan Malaysia (The National University of Malaysia), Jalan Raja
Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
Full list of author information is available at the end of the article

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AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 2 of 13

Keywords: Dental management, Autism spectrum disorders, Dental care, Dental setting, Behaviour modification,
Thinking differences, Learning differences

Highlights

• Explores deeper knowledge and understanding of psychological approach for managing children with ASD in a
clinical dental setting.
• Highlight the impact of such intervention on dental anxiety, the level of children’s cooperation, and the success
of the implementation of dental procedures, which will help the dentists to meet and treat children with ASD
according to their individual needs.
• Discuss the evidence in favour of the use of behaviour management in reducing anxiety and enhancement of
cooperation in children with ASD at the dental setting.

Introduction the effectiveness of specific behavioural or psychologi-

Children with autism spectrum disorders (ASD) com- cal approaches either on oral care or as a communica-
monly face anxiety and fear when undergoing dental tion-aided intervention [11, 12], general strategies of
treatment, as manifested via difficult behaviours and ASD management in a dental office [13] and visual aid
uncooperative reactions [1, 2]. The special congestive approaches (visual pedagogy) using either printed or
profile of autistic children and the specific process related electronic materials [14, 15].
to the response and adaptability to the surrounding envi- So far, the effectiveness of more recent pharmacologi-
ronment exhibit a wide spectrum of behaviour altera- cal and psychological (non-pharmacological) strategies
tions [3, 4]. Children with ASD often show prominent to improve the dental management of children with ASD
characteristics of aggressiveness, unresponsiveness, lack has not been reported systematically and are not well
of attention, and the presence of other medical signs that known to most dental professionals. Therefore, this sys-
may compromise the dental treatment plan [1]. In addi- tematic literature review aimed to evaluate the effective-
tion to ASD, the term autism spectrum condition (ASC) ness of available reported behaviour management and
has also been used to emphasise on the biomedical diag- modification strategies for children with ASD to over-
nosis of the learning and thinking differences in affected come the anxiety and discomfort associated with the
individuals [5]. This issue further complicates the fact treatment in dental clinics. This review may provide the
that several studies have found that the oral health of necessary evidence for clinical guidelines on the manage-
children with ASD is worse than that of typical children ment of dental anxiety, the acceptance, success rates, and
due to lack of awareness among the dental community in impact of each approach with the aim of improving the
how to increase a caregivers’ oral hygiene practices for oral health status and wellness of the children.
their children, difficulty in accessing dental care facilities,
and the knowledge and attitude of dental professionals Materials and methods
towards the children [6, 7]. This systematic literature review was conducted in
Communication between the child and dental team in compliance with the “Preferred Reporting Items for
clinic can be very difficult or restricted [8] if there is no Systematic Reviews and Meta-Analysis” (PRISMA
standard protocol to manage these children especially 2020 statement). It is registered under the “Interna-
while being treated. Thus, the dental team must attempt tional Prospective Register of Systematic Reviews”
different ways of communications, behavioural manage- (CRD42021273415), and received approval for conduct
ment, and pharmacological management to control the by the research ethics committee (UKM PPI/111/8/
child [9, 10]. Altered behaviours among autistic children JEP-2020-757).
and their tendencies of self-injury further increase the
risk of unresponsiveness or even trauma during dental
treatment and prevent the clinicians from performing Search strategy and definitions
comprehensive dental treatment. In such scenarios, more The PICO strategy was utilised in answering the
aggressive techniques such as Protective Stabilization research questions: What is the impact of special tech-
Board (papoose) or general anaesthesia may be required niques in dental management for children with autism
[6], and these may not be well-received by patients and spectrum disorder on their cooperation while under-
caregivers. Alternatively, some studies have focused on going treatment in dental clinic? The study population
(P) of interest was children with ASD within the range

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AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 3 of 13

of 2–18 years old who were receiving interventions (I) scales or cooperation rate. Studies that focused only on
including special dental management techniques in the perceptions and concerns of the caregivers or those
the dental setting as well as other intervention aimed with insufficient information on the outcome were
at improving the success and cooperation of children excluded from the review.
while receiving dental treatment. The results from this
survey were compared (C) with healthy children, chil- Study selection
dren with any other disabilities, or another ASD group The articles obtained from the search were exported into
receiving other intervention(s). The expected out- Microsoft Excel. The list of articles was screened for repli-
come (O) from the intervention was the improvement cates and their relevance to the study title. Any duplicates
in cooperation during dental procedures as rated by or non-ASD-related articles were rejected. Two research-
dental professionals or caregivers, improvement in the ers (MS and SE) screened the titles and abstracts of all
behaviour scale, and a decreased level of anxiety. the retrieved full-text articles to filter out those that were
not relevant to the research question. If there was some
disagreement on the relevance of the articles between the
Selection criteria two researchers, it would be resolved through discussion
The search strategy was carried out in the follow- with the other three reviewers (S.M-S., Z.S, and I.N.B.).
ing database: Scopus, Web of Science, PubMed, and
Cochrane, as well as grey literature searches included Data extraction
Google Scholar and hand-search the reference lists of For each of the included articles, the following informa-
all included articles and relevant literature reviews. The tion was obtained: general characteristics (authors, year
core keywords included (management) AND (child*) of publication, title, and study design), the sample size
AND ("Autism Spectrum Disorder" OR ASD OR autism of subjects, comparative groups, assessment tools used
OR "Asperger syndrome") AND (dental). The Medical in the study, dental procedures done in each study, type
Subject Headings, MeSH (https://​meshb.​nlm.​nih.​gov/​ of management or techniques as intervention, outcome
search) was also used to identify words and phrases measures (e.g. improvement in the anxiety and behaviour
from articles of interest (Table 1). No time limit was set scores, changes before and after intervention related to
in this search. improvement in achievement in planned dental proce-
The inclusion criteria were: original full-text papers dure to be implemented), and lastly key findings.
for studies involving children of 2–18 years old, ran-
domised controlled trials (RCT) or all designs of non- Risk of bias assessment
randomised controlled study (NRS), i.e. non-RCT, The reviewers assessed the risk of bias of the included
interventional study, studies with comparative groups, studies independently. Studies with NRS designs were
interrupted time series study, cohort study, controlled evaluated using the ROBINS-I “Risk Of Bias In Non-ran-
before-and-after study, and case series (uncontrolled domised Studies-of Interventions” and the studies were
longitudinal study). Furthermore, the full-text article rated with the same coding of the data extraction pro-
must be written in the English language and report the cess. The seven domains of ROBINS-I assessed are risk of
impact of the intervention in the form of behaviour bias arising from (confounding, selection of participants,

Table 1 Search strategy for literature

Database Search string Limits/Inclusion

SCOPUS (TITLE-ABS-KEY (“Autism Spectrum Disorder") OR TITLE-ABS-KEY (ASD) OR TITLE-ABS-KEY Language: English Document: Articles
(autism) OR TITLE-ABS-KEY ("Autistic Disorder")) AND TITLE-ABS-KEY (child*) AND TITLE-ABS- Stage: Final
KEY (dental) AND TITLE-ABS-KEY (management) AND ( LIMIT-TO (PUBSTAGE, "final")) AND
(LIMIT-TO (DOCTYPE, "ar")) AND (LIMIT-TO ( LANGUAGE, "English"))
Web of Science [TS = (child*) AND TS = ("Autism Spectrum Disorder" OR ASD OR autism OR "Asperger syn‑ Language: English
drome") AND TS = (management) AND TS = (dental)] Timespan: All years
Indexes: SCI-EXPANDED, SSCI, A&HCI,
CPCI-S, CPCI-SSH, BKCI-S, BKCISSH,
ESCI
PubMed (management) AND (child*) AND ("Autism Spectrum Disorder" OR ASD OR autism OR "Asper‑ Language: English
ger syndrome") AND (dental) Full text
Cochrane (management) AND (child*) AND ("Autism Spectrum Disorder" OR ASD OR autism OR "Asper‑ Language: English
ger syndrome") AND (dental)

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AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 4 of 13

classification of interventions, deviations from intended K = 0.86). Additionally, two papers were added scan-
interventions, missing data, measurement of outcomes, ning the references lists of eligible papers. The step-
selection of the reported result) respectively. In addi- by-step search and selection strategy is shown in Fig. 1
tion, the bias of the RCT studies was evaluated using ver- using the PRISMA template for systematic literature
sion 2 of the Cochrane Risk-of-bias tool for randomised review [18].
trials (ROB-2) and the data in the table were generated
using the Excel tool provided by the same team. The five
domains of ROB-2 assessed are risk of bias arising from Characteristics of the studies
(randomization process, deviation from the intended Of the 15 articles selected, 8 were RCT [19–26] and 7
interventions, missing outcome data, measurement of were NRS; of which three were interrupted time series
outcomes, and selection of the reposted results) respec- study (ITSSs) [27–29]. All the included studies were
tively. Criteria for reaching the overall judgements for organised according to the year of publication and
studies included in both (ROB-2 or ROBINS-I) tools intervention approach. The total number of children
were performed in compliance with the guidelines for involved were 904, of which 862 were children with
each tool [16, 17]. Meanwhile, the inter-evaluator reli- ASD. The age of the children ranged from 2–18 years
ability was calculated using Kappa statistics. with a predominance of male children across the stud-
ies. The range of the time interval was two months in
Results between of analysis (Table 2).
Study selection In most studies, the cooperation of children during
Final search date was 1st January 2022. The initial dental assessment was the most frequent tool used to
search retrieved 202 papers from four databases; 65 assess the impact of the approach used [20, 22, 25, 27,
were found to be duplicates. One hundred and nine 29, 30], followed by the success of oral examination
papers were excluded due to the irrelevance of titles [26, 31, 32], caregivers’ preference [21, 33], number of
and/ or abstracts (Agreement between reviewers was dental appointments to perform the planned procedure
high, K = 0.92). Fifteen were excluded based on full- [19], customised engagement checklist [28], and lastly,
text ratings (Agreement between reviewers was high,

Fig. 1 Summary of literature selection process for systematic review

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AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 5 of 13

Table 2 Description of reviewed studies

Studies Design and assessment Children involved Comparative groups Dental procedures received
tool

Lefer et al. 2019 [27] Interrupted time-series 52 ASD children and ado‑ No control group Clinical oral assessment
study lescents:
Cooperation of children in 3–19 years old
dental assessment 7 females, 45 males
Zink et al. 2018 [19] Randomised clinical trial 40 children with ASD: Two groups: Dental prophylaxis using low-
Number of dental appoint‑ 9–15 years old Application group: speed handpiece
ments needed to perform 2 females, and 38 males (2 females, 18 males) Topical fluoride application
the procedure PECS: (20 males)
Hidayatullah et al. 2018 [28] Interrupted time-series 13 children with ASD: One ASD group Dental examination
study 5–18 years old
Customised engagement 2 females, 11 males
checklist on 10 stages of the
procedure
Nilchian et al. 2017 [20] Randomised clinical trial 40 children with ASD: 20 children in each group Fluoride therapy
Cooperation of children in 6–12 years old
clinical examinations 3 females, 37 males
Tounsi et al. 2017 [31] Retrospective cohort study 168 children with ASD: No control group Dental examination only
The success of dental 4–18 years old
examination 28 females, 140 males
Murshid et al. 2017 [33] Cross-sectional non- 40 children with ASD: No control group Oral examinations
randomised controlled trial 5–9 years old Prophylaxis, and topical fluo‑
study 10 females, 30 males ride applications
Parents’ evaluation and
procedures performed
Nelson et al. 2017 [30] Retrospective cohort study 168 children with ASD: No control group Dental examination
Successful dental examina‑ 4–18 years old
tion 29 females, 139 males
AlHumaid et al. 2016 [32] Retrospective cohort study 44 children with ASD: 22 in each group 70% received dental treat‑
Frankl behaviour rating 5–18 years old ment:
scale and dental procedures 14 females, 30 males Cleanings (50%)
completed Restorative treatment (18%)
Extractions (2%)
Marion et al. 2016 [21] Randomised controlled trial 40 children with ASD and No control group No treatment given
study their caregivers:
Caregivers’ preference via 18 years old
questionnaire 6 females, 34 males
Mah & Tsang 2016 [22] Randomised control trial 14 children with ASD: Two ASD group Dental examination
Cooperation of children in 3–8 years old Tell-show-do with visual
dental assessment 14 males pedagogy = 7
Tell-show-do only, N = 7
Cagetti et al. 2015 [29] Interrupted time-series 83 children with ASD: Three groups undergoing Children underwent four
study 6–12 years old same intervention: stages:
Acceptance rate of the 18 females, 65 males 6–7 years An oral examination (stage 1)
treatment 8–9 years A professional oral hygiene
10–12 years session (stage 2)
Sealants (stage 3)
If necessary, a restorative
treatment (stage 4)
Cermak et al. 2015 [23] Crossover randomised trial 44 children: 22 ASD children Oral examination
Physiological stress and 6–12 years old 22 non-ASD children Prophylaxis (dental cleanings)
anxiety, measured by elec‑ 16 females, 28 males Fluoride application
trodermal activity (EDA)

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AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 6 of 13

Table 2 (continued)
Studies Design and assessment Children involved Comparative groups Dental procedures received
tool

Isong et al. 2014 [24] Randomised controlled trial 80 children with ASD: Each group had 20 children Extra-oral and intra-oral exam‑
study 7–17 years old Four groups: inations with radiographs
Venham Anxiety and Behav‑ 15 females, 65 males Group A: Usual care Scaling (if needed)
iour Scales Group B: A DVD video of a Prophylaxis
typically developed child Application of fluoride varnish
having a dental appoint‑
ment was used for video
peer modelling
Group C: Sunglass-style
video eyewear was used
to view a favourite movie
during a dentist visit
Group D: Video of peer
modelling plus video
goggles
Orellana et al. 2014 [25] Non-randomised control 72 persons with ASD: 38 children and 34 adults Clinical oral assessment
trial 4–41 years old
Cooperation of children in 24 females, 38 males
dental assessment
Lowe & Lindemann 1985 Randomised controlled trial 40 children: 20 ASD children Extra-oral and intra-oral
[26] study Mean age 12.5 years old 20 non-ASD children examination with radiographs
Successful oral examination 12 females, 28 males

behaviour rating scales such as Frankl [32], electroder- visual pedagogy on mobile devices or iPad applications
mal activity (EDA) [23], and Venham [24]. was found to confer a more superior impact on the out-
come compared to the printed materials [19, 21, 29]. One
Outcomes of the intervention approach study in this review focused on the use of digital visual
In this systematic review, the main outcome was deter- pedagogy as the main approach [27]. Also, the standard
mined by the improvement in the child’s cooperation clinical dental examinations without any visual pedagogy
during dental procedures as rated by dental professionals approach were compared with examinations with use of
or caregivers. Another main outcome was the improve- printed materials [20], and use of video materials (DVD,
ment in the behaviour and decrease in the anxiety level video goggles, and video modelling) [24]. Meanwhile, the
of the children in the dental setting. Accordingly, the desensitisation programme led to an improvement of the
measures of effect for the outcomes reported in the stud- children as seen on the Frankl behaviour scale [30, 31],
ies were the increase in the success rate or completion of especially when compared to the standard behaviour
dental procedure, i.e., the increase in the number of com- guidance approaches that included tell-show-do (TSD),
ponents achieved in a dental visit, and/ or improvement voice control (VC), passive restraint, active restraint
on the behaviour rating scales. (AR), and pharmacological options such as nitrous oxide
All the approaches were evaluated according to the (NO) [32]. The positive reinforcements supported with
planned procedure. Most of the studies focused on the TSD showed superiority when compared with negative
clinical oral assessment and examination as main dental reinforcements [26]. Finally, another impressive approach
procedures to be assessed [22–31, 33]. Some other stud- was the “Treatment and Education of Autistic and related
ies focused on more advanced procedures such as dental Communications Handicapped Children” (TEACCH)
prophylaxis and topical fluoride application [19, 20, 23, that included all the communication strategies such as
24, 29, 33]. Only two studies focused on dental treatment TSD and visual pedagogy to educate and manage the
such as restorative treatment and extractions [29, 32] children with ASD [25] (Table 3).
(Table 3).
A variety of approaches have been proposed to improve Risk of bias assessment
the management of children with ASD. So far, visual ped- The characteristics of the studies were assessed individu-
agogy appeared as the most common approach [28]. It ally to evaluate the outcomes and effects of the interven-
can be in the form of printed materials that demonstrate tions using the specific tools based on the study design
the dental settings and procedures in a colourful way (Table 2).
to the parents and/ or children [28, 33]. Digital-based

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 Table 3 Intervention techniques for managing children with ASD
Studies Description of method of intervention Outcomes of intervention
Control Test

Lefer et al. 2019 [27] No control groups çATED app showing pictures of dental examination 65.4% percentage individuals showed improved com‑
using iPad pliance during oral assessment
Time interval:
AlBhaisi et al. BMC Oral Health

Eight months (evaluation at two-, four-, six-, and eight-

month)
Zink et al. 2018 [19] Picture exchange communication system by flash‑ A communication app consists of representative Decrease in number of dental visits and attempts to
cards with pictures of routine at dental office images accompanied by written and corresponding acquire each skill between two groups (3/5) respec‑
audio comments describing the phases of the dental tively
treatment Time interval:
(2022) 22:162

Not applicable
Hidayatullah et al. 2018 [28] No control group (Applied Behaviour Analysis) ABA based management Improvement in behavioural stages for 11 children
methods using image cards One child was able to complete all stages
Time interval:
Treatment was conducted four times at one-week
intervals for a month
Nilchian et al. 2017 [20] Standard examination without any intervention Visual pedagogy (set of colouring pictures illustrated Cooperation during fluoride therapy increased in the
dental examination steps) case group (6/1) respectively
Cooperation in the control group did not increase in
most stages
Both groups presented the same findings in opening
of mouth and showing the teeth, or entering the office,
and sitting in the chair or examination with mirror
Time interval:
Practices for 8 weeks
Tounsi et al. 2017 [31] No control group Dental desensitisation 77% of ASD children were successfully examined within
1 to 2 visits in compared to 88% by the fifth visit
12.5% could not receive dental examination
Time interval:
Two visits only
Murshid et al. 2017 [33] No control group A children’s book preparing children and their parents 47.5% of ASD children acted positively during the
for the first dental visit dental procedure
37.5% showed positive effect on the behaviour of
children according to their parents’ evaluation
Time interval:
6 months (evaluation at week-1 and 4 months)
Nelson et al. 2017 [30] No control group Progressive desensitisation with individualised Minimal threshold examination (MTE) was achieved for

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reinforcements. (The child is gradually exposed to 77.4% of all children within 1 to 2 visits and 87.5% in 5
glimpses from the dental setting that cause anxiety, visits or less
and rewards as positive reinforcement.) Desensitisation was effective in achieving an MTE for
most children
Time interval:
5 dental visits
Page 7 of 13
 Table 3 (continued)
Studies Description of method of intervention Outcomes of intervention
Control Test

AlHumaid et al. 2016 [32] Standard Behavioural Guidance Techniques (SBGTs) D-TERMINED Programme used the familiarisation D-TERMINED programme group had significantly lower
including tell-show-do (TSD), voice control (VC), process through the philosophy of repetitive tasking referral rate compared to the SBGTs group
nitrous oxide (NO), passive restraint, and active Frankl scale showed significant improvement in the
AlBhaisi et al. BMC Oral Health

restraint (AR) behaviour of test group in compared to SBGTs group

52% of participants showed improvement in behaviour
Time interval:
Mean number of dental visits: 2–6
Marion et al. 2016 [21] No control group Dental stories available via different media (paper, Nine (64%) caregivers found the dental story useful
tablet computer, and computer) Two (14%) caregivers found the aid was only helpful for
(2022) 22:162

themselves
Time interval:
6-month until follow-up survey was completed
Mah & Tsang, 2016 [22] TSD (tell-show-do) only Visual pedagogy with TSD method Cooperation level during dental treatment increased
Completed more steps in final appointment
Decreased time required to achieve child cooperation
Lower level of behavioural distress
Time interval: 3 weeks
Cagetti et al.2015 [29] No control group Visual aid: Sketch of the steps of the four planned 77 subjects (92.8%) overcame both stage 1 and 2
dental procedures: 6 subjects (7.2%) refused stage 3
(Oral examination, dental hygiene appointment, fis‑ 3 subjects (7.2%) refused stage 4
sure sealants, and restorative procedure) Time interval:
1.5 months
Cermak et al. 2015 [23] Regular dental environment (RDE) – existing practise Sensory adapted environment (SADE) applied in the Significant decrease in electrodermal activity (EDA) in
and setting dental environment in three aspects, i.e. visual, audi‑ SADE compared to RDE
tory, and tactile: Effect size of the SADE vs RDE (0.23ASD/0.29 non-ASD)
Visual: Shading the windows with curtains and turn‑ Time interval:
ing off the dental chair 3–4 months
Auditory: playing rhythmic music lamp
Tactile (deep pressure): papoose board looks like a
butterfly with its wings
Isong et al. 2014 [24] Usual care (Group A) Group B: A DVD video of a typically developed child Between visits 1 and 2, the mean anxiety and behaviour
having a dental appointment was used for video peer scores decreased significantly among subjects within
modelling groups C and D compared to others
Group C: Sunglass-style eyewear was used for children Time interval:
to view a favourite movie during a dentist visit 6 months (evaluated baseline and at the end of the
Group D: Video of peer modelling plus video goggles study)
Orellana et al. 2014 [25] No control group TEACCH-Based Approach (Treatment and Education The mean number of steps achieved significantly

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of Autistic and related Communication-handicapped increased in children between pre- and post-interven‑
Children) tion
Time interval:
4 weeks (evaluated baseline and at the end of the
study)
Page 8 of 13
 AlBhaisi et al. BMC Oral Health
(2022) 22:162

Table 3 (continued)
Studies Description of method of intervention Outcomes of intervention
Control Test

Lowe & Lindemann, 1985 [26] Negative reinforcements (e.g. “you won’t get lunch”), if Positive reinforcements, with tell-show-do (TSD) Using Positive reinforcements (85% ASD/ 90% Non-
positive reinforcements (e.g. rewards) failed ASD) was successfully examined on first visit
Negative reinforcement was used among 8 ASD and 2
Non-ASD children
ASD/Non-ASD (10/18) patients underwent bitewing
radiographs
Time interval: NA

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Page 9 of 13
AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 10 of 13

Fig. 2 Risk of bias assessment a Traffic light plot of RCTs using the ROB-2 tool. b Summary plot of RCTs using the ROB-2 tool

The reviewers assessed the quality of the eight RCTs dental management for children with ASD. Behavioural
using Version 2 of ROB-2 [19–26] (Fig. 2). Six studies management is a central component of paediatric den-
were judged as having a high risk of bias [21–26] and two tistry while behavioural modification focused on dealing
with a moderate risk of bias [19, 20]. with the problem, challenges, or avoidance behaviours to
The seven NRS studies were assessed using the ROB- ease dental treatment and perform the planned proce-
INS-I tool. Five studies were judged as having a serious dures [34].
risk of bias [27–30, 32] and two with critical risk of bias In the included studies, various approaches were used
[31, 33] (Fig. 3). to improve the management of children with ASD. The
significance of behavioural modification in the dental set-
ting was also highlighted. Many behavioural scales have
Discussion been developed and validated to measure the level of
In this review, we took into consideration the substantial behaviour and its association to anxiety and fear among
difference between behavioural management and behav- children. Frankl behavioural rating scale is one of the
ioural modification in line with the proper definition of most widely used. It categorises the children’s behaviour

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AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 11 of 13

Fig. 3 Risk of bias assessment of non-randomised studies of intervention (NRSI) using the ROBINS-I tool

into four groups based on their attitude and cooperation cooperation during the dental examination [30, 31], espe-
during dental treatment [35]. Additionally, the Venham cially among children with moderate ASD. Desensitisa-
scale was developed to rate the level of anxiety and unco- tion programmes, such as D-TERMINED are built on
operativeness of the child towards dental stress [36]. familiarisation and repetitive tasking of specific proce-
In this review, most of the studies focused on visual dures, also known as the Sensory Adapted Environment
pedagogy since it was one of the conventional approaches (SAE) that was developed from the Applied Behaviour
to manage children in the dental setting. Visual pedagogy Analysis theory (ABA). The desensitisation programme
in the form of printed material such as dental stories or was found to be superior to the standard behavioural
coloured books about dental treatment can help the par- guidance approach that included communication strate-
ents and/ or children to adapt faster to the dental envi- gies, restraint, and even the pharmacological options as
ronment [28, 33]. Additionally, digital visual pedagogy nitrous oxide (NO) [32].
materials including mobile devices/ iPad applications Next, the positive reinforcements supported by TSD
such as çATED app and Picture Exchange communica- also showed an improvement in cooperation during den-
tion system (PECS) were more impactful than the printed tal examination compared to negative reinforcements
materials [19, 21, 27, 29]. The standard examination [26]. Finally, one of the most impressive approaches,
showed a clear improvement with the introduction of “TEACCH” that incorporated all the communication
printed materials, especially during fluoride therapy [20]. strategies such as TSD, visual pedagogy approaches was
Meanwhile, video materials such as DVDs, video goggles, beneficial in the management of children with ASD in the
and video modelling also improved the mean anxiety and dental setting [25] (Table 3).
behavioural scores [24]. For the NRSI, it was rare for the overall judgement of
Furthermore, the desensitisation programme was asso- bias to be low due to confounding. For this review, we
ciated with an improvement in the Minimal Threshold accepted the outcomes at all levels from all the included
Examination (MTE) and behavioural level of the chil- papers, unless the paper did not show sufficient ability to
dren, as manifested by an improvement in children’s produce a valid conclusion.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

AlBhaisi et al. BMC Oral Health (2022) 22:162 Page 12 of 13

There are several limitations to this study. Most of the Universiti Kebangsaan Malaysia (The National University of Malaysia), Jalan
Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia. 4 Applied Oral Sciences
included studies had a small sample size hence may not and Community Dental Care, Faculty of Dentistry, The University of Hong
be able to fully demonstrate the optimal benefit of spe- Kong, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong
cific behavioural strategies on the children from com- Kong.
pared groups. Furthermore, some studies lacked control Received: 10 March 2022 Accepted: 25 April 2022
groups. Qualitative assessment could also benefit from
the studies in addition to qualitative parameters meas-
ured to provide in-depth response on behavioural modi-
fication effects [37–39].
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