In the SADE research clinic at Children’s Hospital Los Angeles, sensory adaptations to the environment were found to significantly reduce autistic children’s physiological and behavioral stress during dental cleanings. CREDIT: Phil Channing/USC
New research conducted by USC researchers at Children’s Hospital Los Angeles reveals that creating a sensory adapted dental clinic environment can significantly reduce the distress experienced by autistic children during oral care.
“According to lead author Leah Stein Duker, assistant professor at the USC Chan Division of Occupational Science and Occupational Therapy, our research has demonstrated that utilizing a combination of carefully selected visual, auditory, and tactile adaptations can significantly reduce behavioral and physiological distress in autistic children during dental cleanings. These adaptations are easy to implement, relatively inexpensive, and do not require specialized training to use.”
Autistic children often face more difficulties with oral health care compared to their typically developing peers. These challenges are often linked to heightened responses to sensory input. The dentist’s office can be overwhelming for them due to bright fluorescent lighting, loud electric hand tools, and reclining chairs. Stein Duker and the Sensory Adapted Dental Environments (SADE) research team, along with colleagues from the Ostrow School of Dentistry of USC, are working on identifying and testing novel approaches to help address these challenges and improve access to effective oral care.
This study involved providing dental cleanings to autistic children 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. The children could choose between a “Finding Nemo” underwater scene or lava lamp-style abstract colors. Additionally, a portable speaker played calming nature sounds and quiet piano music. To provide deep pressure and a hugging sensation, a traditional lead X-ray bib was placed on the child’s chest, and a “butterfly” wrap was secured around the dental chair, from shoulder to ankle, which has been shown to calm the nervous system.
Electrodes were placed on the child’s fingers to measure electrodermal activity, which is a physiological marker of sympathetic nervous system activation, similar to the fight-or-flight response. The researchers also noted the frequency and duration of distressed behaviors displayed by the child during the cleaning, such as pulling away from the dentist, clenching the jaw, attempting to bite the dentist or prevent tools from entering the mouth, crying, and screaming.
The researchers found no differences in the quality of care provided in the adapted environment compared to the regular environment. They also did not find significant differences in the amount of time required to get the child seated and ready for the cleaning, demonstrating that adaptations do not create logistical hurdles.
“So many interventions try to change the person,” Stein Duker said. “Instead, this intervention sees children for who they are. It does not try to fix or change them. The focus of the intervention is to modify problematic environmental factors in order to empower the child and family to successfully engage in occupation.”
Adaptations can make all the difference
This publication is the most recent output from the SADE research project, which is led by Principal Investigator Professor Sharon Cermak and has been ongoing since 2011. The SADE intervention has been tested in pilot studies with various populations in several countries. However, Stein Duker noted that this study is the first to have a sample size large enough to achieve full statistical power.
“Because it’s a fully-powered study, we were able to identify some other very exciting findings,” Stein Duker said. “For example, our data showed that children’s Did you mean “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 behavioral distress during the cleaning.”
The researchers also identified factors predicting the success of the intervention for each participant: Younger age, lower IQ, and/or lower expressive communication level were each associated with a greater reduction in participants’ stress.
“My daughter cannot even hear the word ‘dentist,’” said one participant’s parent. “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.”
The study aims to address oral care disparities experienced by autistic children, with a focus on narrowing ethnic disparity gaps. 72% of enrolled children’s parents identified as Hispanic. Data shows that 52% of Hispanic youth aged 2-19 have dental caries, the highest prevalence compared to other ethnic groups. Bilingual team members ensured the full participation of Spanish-speaking participants.
Stein Duker and her Tailored Environmental Modifications lab will next study the effectiveness of a modified SADE for typically developing children with dental fear and anxiety, a major challenge in pediatric dentistry experienced by approximately 20 percent of all US children. 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.
“Stein Duker advises dental professionals and parents to collaborate and use cost-free adaptations like weighted X-ray bibs, sunglasses, or a beanie hat to improve the clinic experience for those with sensory sensitivities.”