Non-pharmacological Behavior Guidance Techniques on Dental Anxiety And Cooperation in Children With Autism: A Systematic Review and Meta-analysis

Summary

Systematic review and meta-analysis of randomized trials evaluating non-pharmacological behavior guidance to reduce dental anxiety and improve cooperation in autistic children. Virtual reality and sensory-adapted environments show promise, but evidence remains limited.

Abstract

Behavior guidance is recommended as a core component of pediatric dentistry, yet the effectiveness of specific non-pharmacological techniques for autistic patients has not been systematically quantified. The researchers systematically searched PubMed, Embase, Web of Science, Cochrane Library, Scopus, APA PsycInfo, CINAHL, and AMED for randomized controlled trials of non-pharmacological behavior guidance techniques in autistic children undergoing dental procedures. Eligible studies enrolled children with a clinical diagnosis of autism spectrum disorder and compared a structured behavior guidance strategy with routine behavior management or another guidance technique, and reported anxiety and/or cooperation outcomes using validated measures. Electronic searches identified 1,242 records; after deduplication, 487 titles and abstracts were screened, 9 full texts were assessed, and 5 trials (n = 445; sample size 19–162) were included. All were conducted in specialist pediatric dental services and focused on non- or minimally invasive procedures, including examination, prophylaxis, and fluoride application. Interventions comprised a multisensory sensory-adapted dental environment, visual pedagogy, electronic media–based guidance (video modeling and video goggles), and immersive virtual reality. Owing to heterogeneity, quantitative synthesis was feasible for only two VR trials that reported Frankl Behavior Rating Scale scores. In the larger parallel-group RCT, VR improved cooperation versus conventional care (mean difference [MD] 0.55, 95% CI 0.23–0.88); the smaller crossover study showed a similar direction (MD 0.39, 95% CI −0.35 to 1.13). Pooled in a fixed-effect model, VR was associated with a moderate improvement of about half a Frankl point (pooled MD 0.52, 95% CI 0.22–0.82). Non-pharmacological behavior guidance techniques may improve clinically relevant outcomes in autistic children during routine dental care. However, pooled quantitative evidence in the present review was available only for virtual reality–related improvements in cooperation, whereas evidence for other techniques, including sensory-adapted environments, remained limited and was based primarily on narrative synthesis.

Introduction

Behavior guidance is commonly conceptualized as a structured process of communication between the dental team, the child, and the parent that aims to alleviate fear and anxiety, foster trust and positive attitudes towards oral health, and permit safe and efficient treatment under the least restrictive conditions^1,2, foster trust and positive attitudes towards oral health, and permit safe and efficient treatment under the least restrictive conditions. Within this framework, non-pharmacological techniques such as communication guidance, positive pre-visit imagery, direct observation, tell–show–do, as....

Protocol

Registration

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹⁹. The protocol was prospectively registered in PROSPERO, the International Prospective Register of Systematic Reviews (registration number: CRD420261368386).

Study design

In this meta-analysis, the primary objective was to determine the effects of non-pharmacological behavior guidance techniques on dental anxiety in children with autism undergoing dental procedures. Within this framewo....

Results

Literature search and screening process

Electronic searches of PubMed (n = 281), Scopus (n = 426), Cochrane Library (n = 25), Web of Science (n = 137), Embase (n = 306), APA PsycInfo (n = 30), CINAHL (n = 37), and AMED (n = 0) yielded 1,242 records (Figure 1). After removal of duplicates, 487 unique records remained and were screened by title and abstract. Of these, studies were excluded because the research type did not meet the inclusion criteri.......

Discussion

In this systematic review, the researchers identified five randomized controlled trials, enrolling 445 autistic children, that evaluated non-pharmacological behavior guidance strategies during routine dental care. Interventions targeted different levels of the care pathway, from global modification of the sensory environment to chairside distraction and pre-visit preparation. Despite this heterogeneity, most trials reported some improvement in anxiety-related or behavioral outcomes. Quantitative synthesis was only possib.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
AMED	Ovid (Wolters Kluwer)	N/A	Allied and Complementary Medicine Database; used for systematic literature searching.
APA PsycInfo	American Psychological Association (via Ovid/EBSCO)	N/A	Psychology database; used for systematic literature searching.
Cochrane Library	Wiley	N/A	Database of systematic reviews and clinical trials; used for systematic literature searching.
CINAHL	EBSCO Information Services	N/A	Cumulative Index to Nursing and Allied Health Literature; used for systematic literature searching.
Embase	Elsevier	N/A	Biomedical and pharmacological database; used for systematic literature searching.
Endnote X9.1	Clarivate	X9.1	Literature management software; used to organize and manage references.
Excel 2016	Microsoft Corporation	2016	Spreadsheet software; used for data extraction.
Frankl Behavior Rating Scale	Academic/Clinical Tool	N/A	Observational scale for assessing child cooperation in dental settings; used as a primary outcome measure.
PubMed	National Center for Biotechnology Information (NCBI)	N/A	Medical literature database; used for systematic literature searching.
R	R Foundation for Statistical Computing	4.5.3	Statistical computing software; used for planned meta-analysis.
Scopus	Elsevier	N/A	Abstract and citation database; used for systematic literature searching.
Venham Anxiety and Behavior Scale	Academic/Clinical Tool	N/A	Scale for measuring dental anxiety and behavior in children; used as an outcome measure in included trials.
Venham Anxiety Scale	Academic/Clinical Tool	N/A	Tool for assessing dental anxiety in pediatric patients; used as an outcome measure in included trials.
Venham Picture Test	Academic/Clinical Tool	N/A	Pictorial scale for evaluating dental fear in children; used as an outcome measure in included trials.
Web of Science	Clarivate	N/A	Citation database; used for systematic literature searching.