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, ask–tell–ask, non-verbal communication, positive reinforcement, distraction, and desensitization are recommended before recourse to more restrictive measures, including protective stabilization, sedation, or general anesthesia^3,4. Emerging evidence from studies in typically developing children indicates that these strategies can lower self-reported dental anxiety, reduce behavioral distress, and attenuate physiological indices of arousal, thereby supporting an individualized approach in which combinations of sensory, cognitive, and communicative methods are tailored to each child’s needs⁵. However, the applicability of this evidence to children with special health-care needs remains uncertain.

Autism spectrum disorder (ASD) is a neurodevelopmental condition that is characterized by difficulties in social communication and interaction, restricted and repetitive patterns of behavior, and atypical sensory processing^6,7. Given the hypersensitivity to sound, light, touch, and changes in routine⁸, the dental environment often becomes a major source of stress⁹. Meanwhile, dental visits frequently trigger marked anxiety and behavioral dysregulation that may manifest as crying, escape attempts, aggression, or self-injury, thereby substantially complicating the delivery of care^10,11. In response to these challenges, behavior guidance strategies have been specifically adapted for dental care in children with autism¹². For example, sensory-adapted dental environments (SADEs) in which lighting, sounds, and tactile stimuli are carefully modified, video modeling that allows the child to observe dental procedures in advance, graduated exposure and desensitization protocols that introduce dental stimuli in small steps, and visual supports such as picture schedules and social stories that clarify expectations and routines have been developed for children with autism^13,14.

These approaches may offer distinct practical advantages over conventional verbal behavior guidance techniques. SADEs may be particularly useful for children whose distress is driven primarily by sensory over-responsivity¹⁵, because they reduce aversive environmental input without relying heavily on verbal comprehension or social reciprocity^13,14. Visual pedagogy and social-story–based approaches may be especially helpful before the visit or across repeated preventive visits because they can improve predictability, rehearse routines, and be delivered at home with caregiver involvement. Electronic media strategies and virtual reality (VR) may provide chairside distraction and sensory shielding during short, non-invasive procedures, particularly for children who tolerate audiovisual devices and respond well to visual input¹⁶. These differences are clinically relevant because they suggest that no single technique is likely to be optimal for all autistic children, and that selection of a behavior guidance strategy should depend on the child’s sensory profile, communication abilities, treatment type, and the practical resources of the dental setting.

Although early studies suggest that these approaches can reduce observable distress, improve cooperation, and, in some cases, lower anxiety ratings during examinations, prophylaxis, and preventive procedures such as fluoride application^4,17,18, most available studies have been small and heterogeneous, often using nonrandomized designs, varying outcome measures, and different combinations of techniques. which prevents quantification of the overall effects of these interventions and precludes meaningful comparison of the relative effectiveness of different behavior guidance techniques in this population. This has limited the ability to quantify their overall effects and to compare the relative effectiveness of different behavior guidance approaches in autistic children. Therefore, this systematic review aimed to evaluate randomized controlled trials of non-pharmacological behavior guidance techniques for children with autism undergoing dental procedures, with a focus on clinically relevant outcomes including anxiety-related measures, observable distress, and cooperation.

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 framework, the population was defined as children diagnosed with autism spectrum disorder who received dental care in clinical dental settings. Interventions were defined as structured, non-pharmacological behavior guidance strategies specifically intended to facilitate dental treatment, including sensory-adapted dental environments, video modeling, graduated exposure and desensitization, communication-based techniques, and visual supports. Comparators comprised routine care. The primary Outcomes of interest were the improvement in anxiety-related measures assessed using validated scales, whereas secondary outcomes included behavioral and cooperation ratings, treatment completion, use of restrictive pharmacological or physical measures, and adverse events.

Literature search

The researchers conducted a systematic search of PubMed, Embase, Web of Science, the Cochrane Library, Scopus, APA PsycInfo, CINAHL, and AMED for English-language articles from database inception to 1 December 2025. The search strategy combined controlled vocabulary (eg, MeSH and Emtree terms) with free-text terms related to children and adolescents, dentistry and dental care, behavior guidance techniques, and anxiety. To maximize sensitivity and reduce the risk of missing potentially relevant trials that may not have been indexed consistently under autism-related terms, autism-specific terms were not used as mandatory search filters; eligibility of studies involving autistic children was instead determined during screening. The full search strategies for each database are provided in the Supplementary Material. To enhance the completeness of the evidence base, the researchers also screened the reference lists of relevant systematic reviews, all included studies, and searched ClinicalTrials.gov for registered randomized controlled trials, including completed but unpublished and ongoing trials.

Eligibility criteria

Studies were eligible for inclusion if they met all of the following criteria: (1) participants were children or adolescents with a clinical diagnosis of autism spectrum disorder receiving dental examination, prophylaxis, or treatment in a clinical dental setting; (2) the intervention consisted of a structured non-pharmacological behavior guidance technique intended to facilitate dental care, such as sensory-adapted dental environments, video modelling, video goggles, graduated exposure and desensitization, communication-based techniques, distraction, positive reinforcement, or visual supports; (3) the comparator was routine behavior management or an alternative behavior guidance strategy without the specific experimental technique under evaluation; (4) the study used a randomized controlled design, including individually randomized, split-mouth, cluster-randomized, or crossover trials; and (5) the study reported at least one clinically relevant outcome, including anxiety-related measures, observable distress, cooperation, treatment completion, or the use of restrictive pharmacological or physical measures.

Studies were excluded if they were animal or in vitro studies, case reports, case series, study protocols, reviews, letters, editorials, conference abstracts, or qualitative studies; if they did not involve autistic children or were not conducted in a dental or oral health care setting; if key outcome data were unavailable or insufficient for effect size calculation even after attempts to contact the authors; or if they were duplicate publications or full texts could not be obtained.

Data extraction

Endnote X9.1 (Clarivate Analytics) literature management software was utilized to organize the records from the literature search. For data extraction, two reviewers independently used a predesigned Excel 2016 (Microsoft Corp., Redmond, WA, USA) spreadsheet to collect information from all studies that met the inclusion criteria. Extracted data included the first author, year of publication, country, study design, setting, sample size, and characteristics of participants (age, sex, diagnostic criteria for autism spectrum disorder, severity or functional level where reported, and relevant comorbidities). Details of the dental procedures (eg, examination, prophylaxis, fluoride application, restorative or other operative treatment) were recorded, together with a description of the intervention and control conditions, including the type of behavior guidance technique, its components, timing, duration, and the personnel delivering it. Outcome-related data included the type and timing of anxiety measures, the specific scales used (eg, validated dental anxiety instruments or observational scales), behavioral or cooperation ratings, treatment completion or interruption, use of rescue sedation, general anesthesia or protective stabilization, and any reported adverse events. Where necessary, numerical data for continuous outcomes (means, standard deviations, and sample sizes) and dichotomous outcomes (number of events and total participants per group) were extracted or derived from text, tables, or figures.

To ensure consistency across trials, all non-pharmacological interventions and control conditions were classified into predefined categories of behavior guidance techniques. Two reviewers independently assigned each study arm to one or more categories, and any discrepancies were resolved through discussion, with involvement of a third reviewer when necessary.

Quality assessment

The methodological quality of the included studies was assessed using the Cochrane Risk of Bias 2.0 tool for randomized trials²⁰. Two reviewers independently evaluated each trial, at the outcome level, across the following domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported result. For each domain, signaling questions were answered according to the published guidance, and a judgment of low risk of bias, some concerns, or high risk of bias was assigned. An overall risk of bias judgment for each key outcome was then derived from the domain-level assessments. Any discrepancies between the two reviewers were resolved through discussion. When consensus could not be reached, a third reviewer was consulted. The results of the quality assessment were summarized in tables and figures and were used to inform the interpretation of the findings.

Statistical analysis

For each eligible comparison and outcome, treatment effects were summarized at the study level and then, where appropriate, combined across trials. For continuous outcomes, mean differences with 95% confidence intervals were calculated when all studies used the same instrument and scale. For dichotomous outcomes, risk ratios with 95% confidence intervals were calculated. When required data were not directly reported, available numerical information from the text, tables, or figures was used, where possible, to derive the necessary study-level summary statistics. Pairwise meta-analysis was undertaken only when at least two clinically and methodologically comparable studies reported the same outcome. In practice, only two virtual reality studies reporting cooperation outcomes on the Frankl Behavior Rating Scale were considered sufficiently comparable for pooling; therefore, quantitative synthesis was restricted to this outcome, and a fixed-effect model was applied. Statistical heterogeneity was assessed using the χ² test and quantified with the I² statistic. Because of the small number of pooled studies, formal sensitivity analyses and publication bias assessment were not undertaken. Owing to the marked heterogeneity across the remaining interventions and outcomes, no additional meta-analyses or network meta-analyses were performed.

Pairwise meta-analysis was undertaken only when at least two clinically and methodologically comparable studies reported the same outcome. Because only two studies evaluating virtual reality reported sufficiently comparable cooperation outcomes using the Frankl Behavior Rating Scale, quantitative synthesis was limited to this outcome. Given the small number of studies available for pooling and the apparent comparability of this subset, a fixed-effect model was applied. Statistical heterogeneity was examined using the χ² test and quantified with the I² statistic. Owing to the marked heterogeneity in interventions, study designs, and outcome measures across the remaining trials, no additional meta-analysis or network meta-analysis was performed. For outcomes with ten or more contributing trials, small-study effects and potential publication bias were to be explored visually using funnel plots and, where appropriate, statistically using tests for funnel plot asymmetry. If sufficient trials formed a connected network of interventions for a given outcome and the assumptions of transitivity were considered reasonable, a random-effects network meta-analysis in a frequentist framework would be considered to estimate relative effects among multiple behavior guidance techniques and, if feasible, to rank interventions. All statistical analyses were performed using R (version 4.5.3), and all tools used in this review are listed in the Table of Materials.

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.