See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/333878974

Autism and Paediatric Dentistry: A Scoping Review

Article · January 2019

DOI: 10.3290/j.ohpd.a42665

CITATIONS READS

6 2,040

7 authors, including:

Juan Carlos Hernandez Cabanillas Josué Roberto Bermeo Escalona

Autonomous University of Baja California Universidad De La Salle Bajío
5 PUBLICATIONS 9 CITATIONS 18 PUBLICATIONS 62 CITATIONS

SEE PROFILE SEE PROFILE

Amaury J Pozos-Guillen
Universidad Autónoma de San Luis Potosí
211 PUBLICATIONS 2,947 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Efficacy of hypnosis in anxiety/pain reduction in children during pulpotomies. View project

Textile Functionalized Scaffold for Bone Regeneration View project

All content following this page was uploaded by Juan Carlos Hernandez Cabanillas on 10 July 2020.

The user has requested enhancement of the downloaded file.



Autism and Paediatric Dentistry: A Scoping Review

Mónica Herrera-Moncadaa / Phenélope Campos-Larab / Juan Carlos Hernández-Cabanillasc /
Josué Roberto Bermeo-Escalonad / Amaury Pozos-Guilléne / Fernando Pozos-Guillénf /
José Arturo Garrocho-Rangelg

Purpose: The objectives of this scoping review were: first, to pose a research question; second, to identify relevant
studies to answer the research question; third, to select and retrieve the studies; fourth, to chart the critical data;
and finally, to collate, summarise, and report the results from selected articles on the dental management of chil-
dren affected with autism.
Materials and Methods: Relevant articles (randomised controlled trials, reviews, observational studies, and clinical
case reports) published over an 11-year period were identified and retrieved from five internet databases: PubMed,
Embase/Ovid, Cochrane Library, Google Scholar, and EBSCO.
Results: By title and abstract screening and after removing duplicates, 25 articles were finally included in the pres-
ent scoping review. According to the extracted data, the following four clinical issues were found to be most impor-
tant: patient behavioural control, prevalence/incidence of dental caries, adverse effects and interactions with
medications, and orthodontic management. Additionally, several useful clinical recommendations are provided.
Conclusions: Paediatric dentists should bear in mind that early diagnosis and treatment, effective communication
skills, and a long-term follow-up of children with autism continue to be the best approaches for achieving enhanced
patient psychological well-being and consequently a better quality of life.
Key words: autism, general management, paediatric dentistry, review

Oral Health Prev Dent 2019; 17: 203–210. Submitted for publication: 10.07.18; accepted for publication: 28.11.18
doi: 10.3290/j.ohpd.a42665

A utism spectrum disorder (ASD) is one of the most com-

mon worldwide lifelong neurobehavioural disabilities, in
which diverse behavioural/cognitive functions are severely
compromised.12,22 The spectrum comprises autism (or
‘classic autism’), Asperger syndrome, childhood disintegra-
tive disorder, and pervasive developmental disorder-not
otherwise specified, which differ in the amount and severity
of clinical issues.10
Autism was first described in 1943 by Kanner,19 and
is a disorder comprising characteristic impaired social
interactions, impaired communication abilities, and re-
stricted/repetitive behavioural attitudes and activi-
ties.10,12,21 ASD is a heterogeneous condition that im-
plies a combination of both genetic and environmental
aetiological factors; for example, advanced maternal age
has been suggested as involved in the pathophysiology
of the disorder. The prevalence rate has been reported to
range from 5.7 to 11.3 per 1000 (i.e. 1 in 88 children
aged 8 years), with a male:female ratio of 4.6:1 and no
ethnic predilection.6,10,19

a Resident, Paediatric Dentistry Postgraduate Program, Faculty of Dentistry,
San Luis Potosi University, San Luis Potosí, SLP, México. Identification of stud-
ies, search and screening in electronic databases.
b Associate Professor, Paediatric Dentistry Postgraduate Program, Faculty of
Dentistry, San Luis Potosi University, San Luis Potosí, SLP, México. Identifica-
tion of studies, search and screening in electronic databases.
c Associate Professor, Faculty of Dentistry, Baja California University, Tijuana,
BC, México. Identification of studies, search and screening in electronic
­databases.
d Associate Professor, Faculty of Dentistry, La Salle University, León, Gto,
México. Identification of studies, search and screening in electronic
­databases.
e Associate Professor, Paediatric Dentistry Postgraduate Program, Faculty of
Dentistry, San Luis Potosi University, San Luis Potosí, SLP, México. Study de-
sign and writing discussion.
f Associate Professor, Medicine Program, Multidisciplinary Unit, Zona Huasteca,
San Luis Potosi University, Cd. Valles, SLP, México. Identification of studies
and writing discussion.
g Associate Professor, Paediatric Dentistry Postgraduate Program, Faculty of
Dentistry, San Luis Potosi University, San Luis Potosí, SLP, México. Study de-
sign, wrote and proofread the manuscript.
Correspondence: Amaury Pozos-Guillén, Facultad de Estomatología, Universi-
dad Autónoma de San Luis Potosí, Av. Dr. Manuel Nava # 2, Zona Universitaria,
C.P.78290, San Luis Potosí, SLP. Mexico. Tel: +52-444-826-2300 x 5134;
e
­ -mail: apozos@uaslp.mx

Vol 17, No 3, 2019 203

Herrera-Moncada et al
Autism affects the limbic system and cerebellum during
brain development in infancy and usually follows a steady
course, without remission, through adulthood.18,19 As au-
tistic children have no dysmorphic characteristics or bio-
logical markers, the diagnostic process is based on behav-
ioural criteria. 16 The disorder is confirmed through
interviews with the parents or caregivers and psychological
testing.29 Clinically, it is mainly based on four specific cri-
teria and marked behaviour features: (i) early onset, prior
to 3 years of age; (ii) severe abnormal patterns of social
relationships; (iii) abnormal verbal and nonverbal commu-
nication development; and (iv) evident manifestations of
restricted, repetitive, and stereotypical behaviour, interest,
and imagination.10,21
The disorder is frequently associated with sensory (e.g.
auditory, visual, olfactory, tactile, or gustatory) deficits and/
or mental disabilities, great dependence on the parents,
epilepsy, communication difficulties, unpredictable and un-
controlled body movements, and increased fear and anxi-
ety.3,11,33 Additionally, autistic children commonly exhibit
damaging oral habits, including tongue thrusting, bruxism,
lip biting, and soft tissue picking. Additionally, their prob-
lematic behavioural management may impede, change, or
reduce access to oral health care, which places affected
children at a higher risk for oral diseases.3,10,18
There is a paucity of studies in the dental literature that
address the fundamentals of dental management in autistic
paediatric patients, with inconsistent findings. This article
presents a scoping review on the oral health of children and
adolescents with autism and identifies their main oral care
needs.
MATERIALS AND METHODS
Design
Scoping reviews are designed to examine the main body of
available published evidence with a broad approach regard-
ing a specific topic to identify the boundaries and the con-
text of that topic, as well as summarise the most important
information and results of the studies included.5 The pres-
ent scoping review was carried out in accordance with that
proposed by Arksey and O’Malley12 and Bragge et al.19 This
framework comprises five steps: (i) designing the research
question; (ii) identifying relevant studies through a literature
search; (iii) analysing selected studies; (iv) extracting and
charting data; and (v) collating, summarising, and reporting
the results.25,28
Research Question
A research question was structured based on the PICO (Pa-
tient/Intervention/Comparison/Outcome) format to scope
the extent of research available on the clinical topic and to
avoid the early exhaustion of literature during the search
process. The research questions was: For children and ado-
lescents with autism, what are the principal oral health care
necessities?
204
Identification of Relevant Studies
To find potentially relevant articles, the electronic data-
bases PubMed, EMBASE/Ovid, Cochrane Library, Google
Scholar, and EBSCO (Dentistry & Oral Science Source) were
searched. Only references published in the last 11 years
(June 2007 to June 2018), whose purpose was to identify
potential clinical needs in paediatric patients with autism,
were screened. To be eligible for review, articles had to
meet the following criteria: randomised clinical trials, obser-
vational studies (cohorts, case-control designs, cross-sec-
tional studies, and clinical case reports), or review articles
written in English or Spanish and focused on children and
adolescents (aged 0-18 years) with autism in the field of
paediatric dentistry. Gray literature, comments, editorials,
short communications, and letters were excluded from the
review.
A comprehensive literature search, electronic and man-
ual, was conducted independently by three authors (MHM,
PCL, and JCHC) to identify appropriate titles and abstracts.
A search strategy was carefully implemented, employing
three major concepts: ‘autism’, ‘children and adolescents’,
and ‘oral health care’. Several search/MeSH terms, key
words, or synonyms were combined and appropriately
adapted for each database. Then, the chosen articles were
retrieved in full-text and were read and assessed by two
other experienced reviewers (JAGR and AJPG) separately for
the final list of studies to be included. The reference lists of
selected articles were also screened to find other poten-
tially eligible studies. Any discrepancy was discussed and
resolved by consensus with the aid of a third examiner
(JRBE).
Data Extraction
Data from eligible studies were extracted and entered into a
predesigned and piloted standardised tracking and review
form to present a narrative account of the relevant literature
and avoid overlapping. From each individual article, the fol-
lowing information was recorded: general characteristics (au-
thors, year of publication, methodological design, study set-
ting); patients’ clinical features (age, gender, medical status,
level of mental/intellectual disability, oral status, etc); type
of oral management (e.g. diagnostic methods, oral-hygiene/
preventive management, behavioural issues, treatment pro-
cedures); main outcome measured; key findings or conclu-
sions; and authors’ recommendations. A judgment concern-
ing whether each outcome was primarily clinician-centred
was also performed. Thereafter, data were collected, de-
tailed, cross-checked, summarised (in tables or charts), and
discussed accordingly. Additionally, the scoping review pro-
cess was structured as a flow diagram (Fig 1).
RESULTS
We identified 139 studies of potential relevance. Follow-
ing removal of duplicates (n = 7), 132 articles were
screened in detail, and 40 of these were selected for
full-text review. Of these, 25 studies (24 in English and
Oral Health & Preventive Dentistry

Records identified through Additional records identified
Identification
database searching
(n = 126)
Records after duplicates removed
(n = 7)
Screening
Records screened
(n = 132)
Included
Full-text articles assessed for
eligibility
(n = 40)
Eligibility
Studies included in
the scoping review
(n = 25)
Fig 1   Flow diagram of literature search.
one in Spanish) were published between 2007 and 2018
and included in the present scoping review. The entire
selection process is described in the flow diagram de-
picted in Fig 1. Additionally, Table 1 presents the general
characteristics of the studies included in this scoping re-
view.1,3,8,9,10,11,14-18,20,21,23-27,29-36 The majority of the
studies retrieved were conducted in the USA and were nar-
rative reviews/guidelines. The remaining studies were origi-
nal investigations: two systematic reviews, five ran-
domised/nonrandomised controlled clinical trials, and five
cross-sectional studies. After exploring the final selection of
the studies, a large amount of relevant clinical information
was condensed. The main findings from this process are
listed in the discussion section.
DISCUSSION
After reviewing the findings of the present scoping review,
five relevant clinical topics were considered of greatest in-
terest for paediatric dentistry practices during the manage-
ment of autistic children and adolescents: (i) behavioural
management; (ii) caries prevalence/incidence; (iii) drug in-
Vol 17, No 3, 2019
Herrera-Moncada et al
through manual search
(n = 13)
Records excluded on relevance
(n = 92)
Full-text articles excluded, with reasons
(n = 15)
Not related to children or adolescents
Related to other disabilities different to
autism
Not directly related to oral care
Language other than English or Spanish
teractions; (iv) orthodontic management, and (v) additional
clinical recommendations.
Behavioural Management
Communication skills, social-interaction abilities, and knowl-
edge of behavioural control are essential when a paediatric
dentist is concerned with modifying a child’s negative be-
haviours.3,16,30,36 Disruptive behaviours typical of children
or adolescents with autism may significantly complicate
paediatric dental care and home dental care, both preven-
tive and rehabilitative, by endangering the patient’s safety
and placing the practitioner and her/his dental team at risk
of injury. These patients exhibit a wide range of behavioural
and understanding patterns: some of these patients are
verbally fluent with average cognitive activity, while others
do not speak or engage in frequent repetitive or self-injuri-
ous behaviours.33 These conditions are frequently accom-
panied by hyperactivity, low frustration threshold, short at-
tention span, impulsivity, agitation, anger, exaggerated
reactions to light and odors, temper tantrums, and self-inju-
rious behaviours.8,30 Anxiety is increased because the pa-
tients are unable to express the fears or reservations that
they experience at the thought of undergoing treatment.11
205
Herrera-Moncada et al

Table 1   List of studies included in the scoping review, with general characteristics and main findings

Author (year) Study ­design Topic Country Main findings

Namal et al27 RCT* Dental caries prevalence between Turkey Children with autistic disorder exhibited
(2007) autistic and normal children lower caries levels compared to non-affected
controls.

Morisaki et al26 Literature The TEACCH visual guide Japan/ TEACCH is a non-pharmacological behaviour
(2008) review and approach based on pictures, Canada guidance method successfully employed in
clinical case drawings, and boxes children with autism.
report

Gómez-Legorburu Literature Behaviour management of Spain The article describes the main protocols
et al14 (2009) review children with autism required to facilitate proper care during
dental visits.

Loo et al21 (2009) Cross- Factors associated with the use
sectional of traditional behaviour
techniques, general anesthesia,
and protective stabilisation in
children with autism
USA Uncooperative behaviour was associated
with younger age and the presence of an
additional diagnosis, and required advanced
behavioural guidance techniques.

Jaber18 (2011) RCT* Caries prevalence, periodontal United Arab Autistic children exhibited higher caries
problems, and other treatment Emirates prevalence, poor oral hygiene, and extensive
needs unmet oral needs.

Hernández and Literature Management techniques reported USA There are no evidence-based procedural
Ikkanda16 (2011) review in the dental/medical literature modifications that address the problematic
behaviour of autistic children in the dental
setting.

Olszewaska and Literature Orthodontic management of Poland Waiting time should not exceed 10-15
Dunin-Wilczyńska30 review children and adolescents with minutes. An attentive routine is
(2011) autism recommended, by maintaining the same
days, times, and dental staff for each dental
visit.

Rai et al31 (2012) Cross- Assessment of oral health status, India Similar dental caries status, poorer oral
sectional salivary pH, and total salivary hygiene, and lower salivary antioxidants
antioxidant concentration were detected.

Lai et al20 (2012) Cross- To identify dental needs and USA/ Main barriers detected were patient’s
sectional barriers to oral health care Singapore uncontrolled behaviour, cost, and lack of
through surveys insurance. Significant variables of unmet
needs were child’s behaviour/dental health
and caregiver’s last dental visit over
6 months ago.

Delli et al10 (2013) Literature Behavioural management of Netherlands/ Dental management of autistic children
review autistic children in the dental Switzerland requires in-depth understanding and
clinic knowledge of well-established behavioural
techniques, which should be implemented in
an individualised manner.

Stein et al33 RCT* Objective and physiological USA Physiological stress, measured by
(2014) measures of behaviour or distress nonspecific skin conductance response, is
in autistic patients highly correlated with manifest poor
behaviour in autistic children.

Udhya et al34 Literature Clinical characteristics, oral India Autistic children and adolescents do not
(2014) review health status, and dental display specific dental features. However,
management poor dental hygiene contributes to an
increased risk of caries and periodontal
problems.

Gupta15 (2014) Literature Oral conditions, epidemiology, Saudi Arabia An interdisciplinary approach including
review diagnosis, and medical psychotherapy, speech therapy, and parental
management. advice help paediatric dentists to manage
the behaviour of children with autism and
deliver optimal oral care.

Isong et al17 RCT* Efficacy of electronic-screen USA These electronic technologies are useful
(2014) media devices in the paediatric tools for reducing fear and lack of
dental office for reducing anxiety cooperation in autistic children.
and increasing compliance

206 Oral Health & Preventive Dentistry

 Herrera-Moncada et al

Author (year) Study d

­ esign Topic Country Main findings
Nelson et al29 Literature Educational and behavioural USA Practitioners should take enough time to
(2015) review approaches understand and know affected patients,
thus applying appropriate principles of
learning and behavioural control.

Wibisono et al35 Cross- Evaluation of the use of dental Indonesia Pictures were easy to understand by the
(2016) sectional visit pictures in children and their patients. These visual tools were considered
parents through interviews successful as communication models for
children with autism.

Elmore et al11 Literature Articles assessing pictures, USA Sociocommunicative and behavioural
(2016) review recent electronic technologies techniques are the preferred approaches for
(videos and mobile applications), reducing dental anxiety in autistic children.
and socio-behavioural intervention Visual devices are potentially useful aids for
this purpose.

Marion et al24 RCT* Use of dental stories consisting
(2016) of photographs integrated with
text and videos to prepare the
autistic patient for the dental
treatment
USA Dental stories showed to be effective for
preparing both children and families for
dental visits.

Mah and Tsang23 RCT* Efficacy of a visual schedule Canada The system has the potential to help autistic
(2016) system (pictures, communication children successfully complete each dental
symbols, or cues) during dental procedure step, with lower distress and in
appointments less time.

Bartolomé-Villar et Systematic Oral conditions of children with Spain No differences were found regarding the
al3 (2016) review autism spectrum disorder and prevalence of dental caries, oral habits,
children with sensory impairments malocclusions, and frequency of trauma;
only oral-hygiene status was considered
worse in autistic children.

da Silva et al8 Systematic To calculate the pooled Brazil/UK Seven included studies reported dental
(2017) review prevalence of dental caries and caries prevalence. Pooled prevalence was
periodontal disease in children or 60.6%. Pooled periodontal disease
young adults with autism prevalence was 69.4% (three studies).
spectrum disorder

Sadia-Fakhruddin RCT* ASD children were introduced to United Arab The use of audiovisual distraction
et al32 (2017) initial and dental non-invasive Emirates significantly decreased the mean heart rate.
treatment sessions with or There was no significant difference in oxygen
without the use cartoon movies, saturation levels between groups.
as visual distractors. Changes in
blood oxygen saturation and heart
rate were recorded

Dangulavanich et Cross- To evaluate the cooperation rates Thailand Patients aged 11-18 years who had
al9 (2017) sectional and the factors associated with attended special education programmes,
clinical behaviour during dental and who showed positive behaviour before
treatment in ASD children dental management, exhibited higher
cooperation during dental treatment.

Al-Sehaibany1 Prospective This study compared the Saudi Arabia The prevalence in ASD children was 87.3%
(2017) cohort study prevalence of oral habits between and in healthy patients 49.3%. The most
patients with ASD and healthy common habits among autistic children were
children over a 14-month period bruxism (54.7%), object biting (44.7%), and
mouth breathing (26.7%).

Zink et al36 (2018) RCT* To assess a novel electronic
application (app) with the aim of
facilitating the patient-dentist
communication among children
with ASD
Brazil The developed app was more effective than
the Picture Exchange Communication
system; fewer attempts and appointments
were needed to accept the different dental
procedures delivered.

*Randomised clinical trial.

Vol 17, No 3, 2019 207

Herrera-Moncada et al
As a consequence, 60%-80% of dentists are unwilling to
manage autistic patients because of their poor behaviour
on the dental chair, the rate of which among affected chil-
dren has been reported to be as high as 80% to 100%. An-
other factor contributing the lack of cooperation of these
patients includes diminished sensory integration and pro-
cessing as well as changes in the child’s daily routines.33
These anomalies represent an important barrier to dental
treatment.29,31 Many practitioners prefer to employ protec-
tive physical-immobilisation devices or pharmacologic ap-
proaches, including sedation or general anaesthesia.33
When indicated, physical restraint procedures should be
employed with strict, appropriate precautions regarding un-
usual body movements, particularly in autistic patients with
a history of seizures, to keep the patient from harm and
always after obtaining parental consent.21 Diverse behav-
ioural guidance techniques specific to autistic paediatric
patients have been recently suggested and discussed.10,11,
13,15,17,18,21,23,24,35 These techniques include, for example,
the presence of parents, the ‘tell-show-do’ method with
brief and specific commands, short dental visits, sensory
integration, gradual desensitisation, positive/negative ver-
bal reinforcement, and the use of audiovisual distractors.
These approaches, alone or in combination, should be per-
sonalised and based on specific, individual needs.
Patients with autism are characterised as visual learners
because they possess neuropsychological features that pro-
mote the preference for strongly processing visual informa-
tion or stimuli over other sensory channels, such as hear-
ing.9,17 Recent investigations have supported the use of
easy-to-understand visual approaches (e.g. pictures, draw-
ings, videos, or electronic mobile applications), combined
with traditional behavioural control methods, to improve
the cooperation level of autistic children or adolescents
and facilitate positive dental visits.11,23,26,32,36 For exam-
ple, low anxiety levels have been reported when patients
with autism previously watched a video of other children
undergoing a dental procedure.23 Similarly, Zink et al36
developed an app for facilitating the communication pro-
cess between autistic paediatric patients and practition-
ers, with fewer dental visits required for clinical examina-
tions and preventive dental care. Additionally, the TEACCH
visual guide approach to controlling a child’s behaviour
and promoting home daily routines is widely recommended
by Morisaki et al.26 Thus, these modeling/communication
tools have been demonstrated to be effective and practical
in the paediatric clinical setting for engaging, teaching, and
motivating patients with autism, reducing fear, and increas-
ing compliance for routine oral examinations or dental pro-
cedures.17
Caries Prevalence and Incidence
A systematic review, or meta-analysis, carried out by da
Silva et al8 included seven relevant studies that reported
the caries prevalence in autistic children and young adults;
the pooled prevalence reported in this meta-analysis was
60.6% (95% confidence interval = 44.0, 75.1). A second
systematic review by Bartolomé-Villar et al3 reported contra-
208
dictory results: some studies showed no significant differ-
ences between affected children and normal controls,
whereas others indicated a higher incidence among autistic
children.3 On the other hand, three cross-sectional studies
evaluated caries prevalence in children or adolescents with
autism compared with nondisabled children as controls.
Jaber18 gathered 61 autistic participants aged 6 to
16 years (16 females and 45 males) who were compared
with a non-autistic control group of 61 participants. Children
with autism had significantly higher numbers of decayed,
missed, or filled teeth (77%) than controls (46%). Rai et
al31 evaluated the oral health status of 101 affected chil-
dren and 50 normal healthy siblings as controls between 6
and 12 years of age; no significant difference was observed
in the dental-caries status of the autistic group and the con-
trol group. Finally, Namal et al27 examined 61 Turkish autis-
tic and 301 normal children between the ages of 6 and
12 years to assess and compare their caries. These au-
thors concluded that patients without the disorder had a
higher caries prevalence than those with autism (odds ratio,
OR = 3.99; 95% CI = 1.56, 10.19). However, the authors
considered that the autistic sample studied was not com-
pletely representative of the population because the major-
ity of these patients were selected from families with ac-
cess to education and special care.
Drug Interactions and Adverse Effects
Many drugs prescribed chronically by psychiatrists to man-
age autism-associated symptoms have adverse effects and
interactions with medication used in clinical paediatric den-
tistry.12 For example, for treating hyperactivity, autistic chil-
dren are managed with central nervous system (CNS) stimu-
lants (Methylphenidate) or antihypertensives (Clonidine); for
repetitive behaviours, medication is based on antidepres-
sants (Fluoxetine or Sertraline); and, in cases of aggressive
patterns, anticonvulsants (Carbamazepine or Valproate) or
antipsychotics (Olanzapine or Riperidone) are adminis-
tered.12 Thus, it is imperative for practitioners to be familiar
with the pharmacological properties of these psychotropic
drugs.15
Similarly, in the practice of paediatric dentistry, pharma-
cological approaches employed for pain and anxiety control
in autistic children and adolescents have been classified as
conscious (oral, inhalatory, intramuscular, or intravenous
sedation) and unconscious methods (deep sedation and
general anaesthesia).7 Although these approaches are use-
ful tools that are often necessary, they are not absolutely
safe or effective and incur additional costs. Although rare,
some associated health risks, adverse effects, and compli-
cations have been reported in the dental literature when
sedatives or general anaesthesia are administered in men-
tally challenged children (Table 2).12,15
Orthodontic Management
Malocclusions occur more frequently in mentally challenged
children, which may compromise several oral functional as-
pects and create adaptive alterations in chewing, swallow-
ing, and language. In this regard, Al-Sehaibany1 reported
Oral Health & Preventive Dentistry

that the prevalence of harmful oral habits (e.g. bruxism,
object biting, thumb sucking/biting, and mouth breathing)
was almost twice as high in ASD patients as in healthy chil-
dren, thus contributing to an increased occurrence of dental
malocclusions. On the other hand, only one article could be
retrieved that addresses the orthodontic management of an
autistic patient.30 As in other dental fields, behavioural con-
trol is the main problem encountered when orthodontically
treating autistic children and adolescents. Thus, when de-
signing the treatment plan, the orthodontist should estab-
lish individual and short-term objectives on a step-by-step
basis. This plan can be reassessed and modified after the
completion of each step, according to the patient’s behav-
ioural evolution. Perfection is not usually an achievable goal
in these children, but therapeutic efforts should be at-
tempted to improve their occlusion. More difficult proced-
ures in orthodontics for autistic patients are impression
taking and bracket bonding. Diverse behavioural control ap-
proaches have been recommended for performing these
and other difficult tasks, ranging from conductive guidance
or educational intervention techniques alone to pharmaco-
logical sedation and general anaesthesia.
Additional Recommendations
Various authors10,11,14-16,18,21,29,33,34 have made different
clinical and practical recommendations for better dental
management of autistic children and adolescents. The
most important ones are: (i) signs of physical abuse should
be looked for during the extraoral and intraoral examination,
for example, oral traumas; (ii) mouth guards are adequate
for patients with severe bruxism or a self-injurious pattern;
(iii) powered toothbrushes may be appropriate and well-tol-
erated but require some training; (iv) the dental light and
instruments should be kept away from the dental chair;
(v) sensory stimuli such as sounds or odors that may dis-
tract the patient should be reduced; (vi) interruptions
should be avoided and only the necessary assistants
should be present in the operatory room; and (vii) the
child’s limited tolerance for physical contact should always
be considered.
Limitations
Unlike systematic reviews, scoping reviews do not incorpo-
rate a quality assessment of the studies included. This
scoping review was aimed at collecting useful clinical infor-
mation that is available and easily accessible to help clin-
icians during the management of children and adolescents
with autism. Through this approach, we intended to define
the scope of the literature relevant to this topic. However,
as with any scoping review, a likely publication bias was
present due to the selection of studies conducted only in
English- or Spanish-speaking countries, primarily due to lim-
ited resources for translation. Furthermore, the article
search was restricted to an 11-year period; thus, our refer-
ence screening might have been underrepresented. How-
ever, we are confident that a significant number of studies
included herein provided an overview and useful information
on the oral health care of autistic paediatric patients. Other
Vol 17, No 3, 2019
Herrera-Moncada et al
Table 2   Potential adverse effects associated with the
use of sedation or general anaesthesia in autistic chil-
dren (taken and adapted from Gupta15 and Elmore et al11
Sedation General anaesthesia
Xerostomia Heart attack
Sialorrhea Stroke
Dysphagia Allergic reaction
Stomatitis Temporary mental confusion
Glossitis Lung infection
Bruxism Damage to the vocal cords
Body pain/headache Waking during anesthesia
Sinusitis Death
limitations of the present study were the high heterogeneity
of the detected articles, our limited ability to consistently
summarise details of the extracted data or findings, and
the difficulties in assigning outcomes to specific domains.
More research effort is necessary to assist paediatric den-
tistry practitioners in achieving more effective oral health
care for ASD children and adolescents, provide improved
dental experiences for ASD patients and, as a consequence,
to contribute to a better quality of life for ASD patients. Cur-
rent and future research should be especially focused on
optimising behaviour control management prior to and during
the dental treatment of this vulnerable population.
CONCLUSIONS
The present scoping review collated and condensed the
major clinical recommendations reported in the relevant
paediatric dentistry literature published over the last
11 years regarding the best approaches for proper dental
management of children and adolescents with ASD in a
non-threatening environment.
It is crucial that paediatric patients with ASD be intro-
duced to dental treatment in an adaptive and progressive
manner to desensitise their enhanced visual, auditory, and
tactile sensations. Individually designed behavioural tech-
niques, for instance, an adequate verbal approach and the
use of diverse visual distractors, can help affected children
cope with dental stressors and exhibit an acceptable coop-
eration level, with less anxiety and apprehension in the clin-
ical setting.
REFERENCES
1. Al-Sehaibany FS. Occurrence of oral habits among preschool children with
autism spectrum disorder. Pak J Med Sci 2017;33:1156–1160.
2. Arksey H, O’Malley L. Scoping studies: Towards a methodological frame-
work. Int J Soc Res Method 2005;8:19–32.
3. Bartolomé-Villar B, Mourelle-Martínez MR, Diéguez-Pérez M, de Nova-Gar-
cía MJ. Incidence of oral health in paediatric patients with disabilities:
Sensory disorders and autism spectrum disorder. Systematic review II. J
Clin Exp Dent 2016 8:e344–e351.
209
Herrera-Moncada et al
4. Bragge P, Clavisi O, Turner T, Tavender E, Collie A, Gruen RL. The Global
Evidence Mapping Initiative: Scoping research in broad topic areas. BMC
Med Res Methodol 2011;11:92.
5. Castro-Codesal ML, Dehaan K, Featherstone R, Bedi PK, Bedi PK, Marti-
nez Carrasco C, Katz SL, et al. Long-term non-invasive ventilation thera-
pies in children: A scoping review. Sleep Med Rev 2018;37:148–158.
6. Centers for Disease Control and Prevention (CDC). Mental health in the
United States: Parental report of diagnosed autism in children aged 4-17
years – United States, 2003-2004. MMWR Morb Mortal Wkly Rep 2006
55:481–486.
7. Chaushu S, Becker A. Behavior management needs for the orthodontic
treatment of children with disabilities. Eur J Orthod 2000;22:143–149.
8. da Silva SN, Gimenez T, Souza RC, Mello-Moura ACV, Raggio DP, Morim-
oto S, et al. Oral health status of children and young adults with autism
spectrum disorders: Systematic review and meta-analysis. Int J Paediatr
Dent 2017;27:388–398.
9. Dangulavanich W, Limsomwong P, Mitrakul K, Asvanund Y, Arunakul M.
Factors associated with cooperative levels of autism spectrum disorder
children during dental treatments. Eur J Paediatr Dent 2017;18:231–236.
10. Delli K, Reichart PA, Bornstein MM, Livas C. Management of children with
autism spectrum disorder in the dental setting: Concerns, behavioural
approaches and recommendations. Med Oral Patol Oral Cir Bucal
2013;18:e862–e868.
11. Elmore JL, Bruhn AM, Bobzien JL. Interventions for the reduction of den-
tal anxiety and corresponding behavioral deficits in children with autism
spectrum disorders. J Dent Hyg 2016;90:111–120.
12. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME. The neuropathology,
medical management and dental implications of autism. J Am Dent
Assoc 2006;137:1517–1527.
13. Ghandi RP, Klein U. Autism spectrum disorders: An update on oral health
management. J Evid Based Dent Prac 2014;14(Suppl):115–126.
14. Gómez-Legorburu B, Badillo-Perona V, Martínez-Pérez EM, Planells-del
Pozo P. Intervención odontológica actual en niños con autismo. Cient
Dent 2009;6:207–215.
15. Gupta M. Oral health status and dental management considerations in
autism. Int J Contemp Dent Med Rev 2014;2014:011114.
16. Hernández P, Ikkanda Z. Applied behavior analysis: behavior manage-
ment of children with autism spectrum disorders in dental environments.
J Am Dent Assoc 2011;142:281–287.
17. Isong IA, Rao SR, Holifield C, Iannuzzi D, Hanson E, Ware J, et al. Ad-
dressing dental fear in children with autism espectrum disorders: A ran-
domized controlled pilot study using electronic screen media. Clin Pediatr
(Phila) 2014;53:230–237.
18. Jaber MA. Dental caries experience, oral health status and treatment
needs of dental patients with autism. J Appl Oral Sci 2011;19:212–217.
19. Klein U, Nowak AJ. Autistic disorder: A review for the pediatric dentist.
Pediatr Dent 1998 20:312–317.
210
View publication stats
20. Lai B, Milano M, Roberts MW, Hooper SR. Unmet dental needs and barri-
ers to dental care among children with autism spectrum disorder. J Au-
tism Dev Disord 2012;42:1294–1303.
21. Loo CY, Graham RM, Hughes CV. Behavior guidance in dental treatment
of patients with autism spectrum disorder. Int J Paediatr Dent 2009;
19:390–398.
22. Lu YY, Wei IH, Huang CC. Dental health - a challenging problem for a pa-
tient with autism spectrum disorder. Gen Hosp Psychiatry 2013;35:214.
e1–e3.
23. Mah JW, Tsang P. Visual schedule system in dental care for patients with
autism: A pilot study. J Clin Pediatr Dent 2016;40:393–399.
24. Marion IW, Nelson TM, Sheller B, McKinney CM, Scott JM. Dental stories
for children with autism. Spec Care Dentist 2016;36:181–186.
25. McKenzie K, Martin L, Ouellette-Kuntz H. Frailty and intellectual and devel-
opmental disabilities: a scoping review. Can Geriatr J 2016;19:103–112.
26. Morisaki I, Ochiai TT, Akiyama S, Murakami J, Friedman CS. Behavior
guidance in dentistry for patients with autism spectrum disorder using a
structured visual guide. J Disabil Oral Health 2008;9:136–140.
27. Namal N, Vehit HE, Koksal S. Do autistic children have higher levels of
caries? A cross-sectional study in Turkish children. J Indian Soc Pedod
Prev Dent 2007;25:97–102.
28. Naseem M, Shah AH, Khiyani MF, Khurshid Z, Zafar MS, Gulzar S, et al.
Access to oral health care services among adults with learning disabili-
ties: A scoping review. Ann Stomatol (Roma) 2017;7:52–59.
29. Nelson TM, Sheller B, Friedman CS, Bernier S. Educational and therapeu-
tic behavioral approaches to providing dental care for patients with au-
tism spectrum disorder. Spec Care Dentist 2015 35:105–113.
30. Olszewaska K, Dunin-Wilczyńska I. Orthodontic management of children
with autism – Review of the literature. Dent Med Probl 2011;48:459–463.
31. Rai K, Hedge AM, Jose N. Salivary antioxidants and oral health in chil-
dren with autism. Arch Oral Biol 2012;57:1116–1120.
32. Sadia-Fakhruddin K, Yehia-El Batawi H. Effectiveness of audiovisual dis-
traction in behavior modification during dental caries assessment and
sealant placement in children with autism spectrum disorder. Dent Res J
(Isfahan) 2017;14:177–182.
33. Stein LI, Lane CJ, Williams ME, Dawson ME, Polido JC, Cermak SA. Physio-
logical and behavioral stress and anxiety in children with autism spectrum
disorders during routine oral care. Biomed Res Int 2014;2014: 694876.
34. Udhya J, Varadharaja MM, Parthiban J, Srinivasan I. Autism Disorder (AD): An
updated review for paediatric dentists. J Clin Diagn Res 2014;8:275–279.
35. Wibisono WL, Suharsini M, Wiguna T, Sudiroatmodjo B, Budiardjo SB, Au-
erkari EI. Perception of dental visit pictures in children with autism spec-
trum disorder and their caretakers: A qualitative study. J Int Soc Prev
Community Dent 2016;6:359–365.
36. Zink AG, Molina EC, Diniz MB, Santos MTBR, Guaré RO. Communication
application for use during the first dental visit for children and adoles-
cents with autism spectrum disorders. Pediatr Dent 2018;40:18–22.
Oral Health & Preventive Dentistry