Results of a University of South California (USC) and Children’s Hospital Los Angeles (CHLA) study of 162 autistic children show that Sensory Adapted Dental Environments (SADE) created more relaxed, less anxious dental care experiences.

Leah Stein Duker, lead author and assistant professor at the USC Chan Division of Occupational Science and Occupational Therapy, said, “We’ve shown that the combination of curated visual, auditory and tactile adaptations — all of which are easily implemented, relatively inexpensive and don’t require training to safely use — led to statistically significant decreases in autistic children’s behavioural and physiological distress during dental cleanings.”

Compared to typically developing peers, autistic children experience greater oral health care challenges, which are often associated with heightened responses to sensory input. The dentist’s office is filled with potentially overwhelming stimuli such as bright fluorescent lighting, whirring electric hand tools and reclining chairs. Leah and the SADE research team, including colleagues from the Ostrow School of Dentistry of USC, are identifying and testing innovative approaches that can help alleviate those challenges in order to increase access to and efficacy of oral care.

In this study, autistic children received cleanings in both a standard clinic environment and an adapted one. In the adapted setting, the dentist wore a surgical loupe with an attached lamp, blackout curtains were hung over the windows, and a slow-motion visual effect was projected onto the ceiling (children could choose between a Finding Nemo underwater scene or lava lamp-style abstract colours). A portable speaker played calming nature sounds and quiet piano music. A traditional lead X-ray bib placed on the child’s chest and a ‘butterfly’ wrap secured around the dental chair provided deep pressure hugging sensation from shoulder to ankle, which has been shown to calm the nervous system.

Electrodes placed on the child’s fingers measured electrodermal activity, a physiological correlate of sympathetic nervous system activation akin to the fight-or-flight response. The researchers also observed the frequency and duration of distressed behaviours exhibited by the child during the cleaning, such as jerking away from the dentist, clamping down with the jaw, intentionally trying to bite the dentist or keep tools out of the mouth, crying and screaming.

The researchers did not find any differences in the quality of care provided in the adapted environment, compared to the regular environment. They also did not find any significant differences in the amount of time required to get the child seated and ready for the cleaning, showing that sensory adaptations do not create adverse logistical, time or scheduling ramifications for clinics.

Leah said, “So many interventions try to change the person. Instead, this intervention sees children for who they are — it does not try to fix or change them — focusing the intervention to modify problematic environmental factors as a way to empower the child and family to engage successfully in occupation.”

Adaptations can make all the difference

This publication is the latest from the SADE research project, led by principal investigator Professor Sharon Cermak, which dates back to 2011. Since then, the SADE intervention has been replicated in pilot studies with a number of different populations in several countries. However, Leah said, this study is the first with a large enough sample size to attain full statistical power.

Leah said, “Because it’s a fully-powered study, we were able to identify some other very exciting findings. For example, our data showed that children’s physiological stress dropped as soon as they entered the adapted dental cleaning room before the actual cleaning even began, and that level of physiological stress predicted behavioural distress during the cleaning.”

The researchers also identified factors predicting the intervention’s success for any given participant: younger age and lower IQ and/or lower expressive communication level were each associated with a proportionally greater reduction in participants’ stress.

In the SADE research clinic at Children’s Hospital Los Angeles, a traditional lead X-ray bib placed on the child’s chest and a ‘butterfly’ wrap secured around the dental chair provided participants a deep pressure-hugging sensation from shoulder to ankle during dental cleanings.

A participant’s parent said, “My daughter cannot even hear the word ‘dentist. But after being in the [SADE] room for a bit, she was able to have her teeth looked at for the first time in over a year.”

Leah and her Tailored Environmental Modifications lab will next study the effectiveness of a modified SADE for typically developing children with dental fear and anxiety. In the near future, she is also planning to collect preliminary data studying adolescents and adults with intellectual developmental disabilities and/or autism, populations she gets frequently asked about at dental conferences and research meetings.

“Regardless of population, my advice to dental professionals and parents alike is to work together to find ways to improve the overall clinic experience,” Leah says. “There are weighted X-ray bibs in every single dental office that may help calm the child; they can wear sunglasses; they can wear a beanie hat covering the ears to muffle noises — all of these are completely free and easy adaptations that have the potential to improve the clinic experience for those with sensory sensitivities, without negatively impacting dentists’ ability to provide care.”

Read ‘Sensory Adaptations to Improve Physiological and Behavioral Distress During Dental Visits in Autistic Children: A Randomized Crossover Trial’ at JAMA Network Open.

Author: