Table 1.

Characteristics of Included Studies

Author/Year	Study design	Country	Sample size	Type of disability	Outcomes	Barriers and facilitators to access
Abduludin et al., (2019) [33]	Qualitative	Malaysia	10 parents/  caregivers	Cerebral Palsy	The study identified five domains of promoting and hindering factors relating to the accessibility of children with CP to oral health care. These were dental experience, family support, mobility, ability to pay and social value.	Barriers: Lack of family support to access care, poor previous experience of services, proximity of parking at the clinic, lack of reasonable adjustments to access dental surgery, societal discrimination about disability Facilitators: Ability to pay, free treatment, dental outreach program, positive attitudes of dental staff, sharing experiences with other parents of disabled children
Al Agili et al., (2004) [35]	Cross-sectional	USA	714 parents	Different disabilities	Association with lack of insurance and difficulty accessing dental services. Waiting times of 3-6 months barrier to access. Length of time in waiting room added to child’s distress.	Barriers: Difficulties in finding willing dentists who accept their health insurance, lack of dentists’ knowledge and training in providing care. Lack of transportation, Scheduling challenges such as long wait times for appointments and extended waiting times at the dental office also hindered access to care. Facilitators: Private insurance coverage
Al Habashneh et al., (2012) [60]	Cross-sectional	Jordan	206 comprising 103 with DS and 103 age and gender-matched non-DS ⁄public school children	Downs Syndrome (DS)	The most common reason cited for not taking children to the dentist for DS group was ‘Not aware of the dental problems of their children	Barriers: Not aware of the dental problems of their children, no awareness of the importance of dental visit, Fear of children as a reason for not taking children to dental care and financial. Facilitators: Not mentioned
AlHammad et al., (2020) [45]	Cross-sectional	KSA	263 parents of autistic children	Autism	A total of 41.4% of the parents visit the dental clinic when the child complains about dental problems and 54% find difficulty in locating appropriate dental clinic to deal with their ASD children. Most parents reported taking their child to a private office (38.8%). Only 3.8% of parents reported that their children had seizures during dental procedures.	Barriers: Dislike of dental treatment, complications related to the medical condition, trouble in locating a competent dentist. Facilitators: Accessibility of a variety of dental services
Allison et al., (2000) [36]	Cross-sectional	France	204 reports on children with DS 161 reports on siblings without DS	DS	Parents of children with DS nearly twice as likely to report problems finding dental services. Parents 20x more likely to use specialist medical services than dental services, indicating low priority for oral healthcare.	Barriers: Time-consuming healthcare, difficulty finding dental services, limited availability of dental services, and a higher reliance on specialist medical services rather than dental services. Insufficient behavior management skills of the general practitioner Facilitators: individuals with DS are more likely to consult a dentist yearly if they also seek speech therapy and ophthalmology services, suggesting an association of health problems and/or of parental health and illness behavior
Al-Shehri, (2012) [64]	Cross-sectional	KSA	119 caregivers	Different disabilities	84.7% of persons with disabilities saw a dentist only for an emergency, and 46.2% reported having difficulty in obtaining dental care in their community. Fear of the dentist (52.1%), cost (48.7%), being unable to sit in the dental chair (28.2%), transportation difficulties (26.9%), distance to the dental clinic (18.5%), and the dentist’s unwillingness to treat those with disabilities (16.8%) were all barriers to dental care for individuals with disabilities	Barriers: fear of the dentist, cost, being unable to sit in a dental chair, transportation difficulty, distance to the dental clinic, and the dentist’s unwillingness to treat those with disabilities Facilitators: Caregivers' higher level of education correlates with improved oral hygiene practices and a higher probability of seeking dental care for individuals with disabilities.
Alshihri et al., (2021) [46]	Cross-sectional	KSA	142 mothers	Autism Spectrum Disorders (ASD)	68.3% of mothers reported difficulty finding a dental care. 75.4% found cost prohibitive. 74.6% reported difficulty finding a dentist willing to treat their child. 72% of dentists visited failed to offer any oral heath advice. Only 45% believed that their child’s behavior would affect their ability to seek dental care.	Barriers: Perceived behavior of child, cost of dental treatment, insurance shortfall, and difficulty finding a dentist who treats autistic children. Facilitators: Not mentioned
Barry et al., (2014) [37]	Cross-sectional	UK	112 / 56 parents/carers of children with ASD 56 parents/carers of children without ASD	ASD	Although there was no significant difference in accessing dental care between the study and control groups, the ASD group perceived it as more difficult. They faced greater challenges in traveling to the dental surgery and exhibited more predicted negative behaviors.	Barriers: Difficulties in transport, cost of treatment, Importance of parking proximity, finding a suitable dentist, long waiting time in the waiting room, difficulties and discomfort experienced by children with ASD during dental procedures, perceived lack of cooperation by the child during dental care, perceived challenging behaviors of children with ASD, difficulty in recognizing dental pain and challenges in communication. Facilitators: Medical insurance and positive experience
Bhaskar et al., (2016) [47]	Cross‑sectional	India	331 differently abled children and their parents	Differently abled children	Financial difficulty was a major barrier to dental care, particularly for intellectually impaired children (39%).	Barriers: Cost of treatment and transportation difficulties, fear of the dentist, perceived inability to cooperate with dental treatments, geographical distance of clinic. Facilitators: Dentists showing willingness to treat children.
Brickhouse et al., (2009) [48]	Cross-sectional	USA	55 caregivers of at least 1 child with an autism spectrum disorder.	ASD	Household income and child’s history of difficult behavior in the dental office significantly related to the ability to receive care when needed and whether the child had a regular dental provider. An inability to find a dentist with the skills or willingness to work with people with disabilities was the most frequent reason cited for not having a regular dental provider.	Barriers: Respondents’ education and income, insurance coverage, the child’s perceived history of behavior in the dental office, inability to find a dentist with special skills or a willingness to work with disabled patients. Facilitators: Insurance coverage and household income
Chi et al., (2010) [61]	Cross-sectional	USA	IDD children (N = 4,385), non-IDD children (N = 103,220)	Children with intellectual and/or developmental disability	Factors such as older age, not residing in a dental Health Professional Shortage Area, interaction with the medical system, and family characteristics increased one’s likelihood of receiving preventive dental care.	Barriers to preventive dental care: younger age, not residing in areas with sufficient dental professionals, limited integration between medical and dental systems, and unequal dentist distribution in urban/rural counties. Facilitators of preventive dental care: Interaction with medical system, having another Medicaid-enrolled child, enrolling children from same low-income families in Medicaid.
Como et al., (2022) [41]	Qualitative	Black/African American, USA	11 caregivers of children with Autism	Autism	Three themes emerged from the data concerning the barriers that affect oral health experiences: (a) difficulty in maintaining good oral health practices, (b) challenges with access to care and resources, and (c) poor patient-provider relationships	Barriers to accessing dental care include financial constraints, dental insurance issues, difficulty finding local dentists, limited community resources, and negative experiences with health care professionals. Facilitators: Not mentioned
De Jongh et al., (2008) [49]	Cross-sectional	Netherlands	61 Children, 126 Caretakers and 40 dentists	Severe mental disabilities	- Ethnic minority children with disabilities had lower access to routine dental care (53.1% vs. 23.8%). -Dutch noninstitutionalized children with severe disabilities received limited quality dental care. -Non-cooperation of patients was a significant challenge for caretakers (68%). -Perceived communication problems were the primary barrier to treatment according to dentists (75%).	Barriers: Children belonging to an ethnic minority not receiving routine oral care. Treatment barriers as indicated by the dentists: Perceived communication problems, lack of financial compensation, lack of experience in treating children with intellectual disabilities, lack of knowledge, and unequipped surgeries. Facilitators: Regular professional oral care and high satisfaction levels reported by dentists and caretakers.
de Souza et al., (2023) [42]	Cross-sectional	Brazil	100 caregivers	ASD	The caregivers reported that 25% of the children had never been to the dentist and 57% had an appointment over the past 12 months. Seeking primary care for dental treatment and frequent toothbrushing were positively associated with both outcomes and participating in oral health preventive activities decreased the chance of never having been to the dentist. Having male caregivers and activity limitations due to autism decreased the chance of having been to the dentist over the past year.	Barriers: Male caregivers and children with profound autism. Facilitators: Knowledge of oral health and carrying out existing oral health practices, as well as participation in an oral healthcare program.
Du et al., (2019) [38]	Case–control	Hong Kong, China	257 pre-schoolers with ASD, 257 without ASD	ASD	Children with ASD had a lower frequency of tooth-brushing and toothpaste usage, but they required parental assistance more often during tooth-brushing (p < .05). Barriers to dental care were more frequently reported among children with ASD (p < .001). Parents of children with ASD had higher scores in dental knowledge and attitudes compared to those without ASD	Barriers: The inability to find a dentist willing to treat the child, difficulty finding a dentist near the child’s home, dental staff being anxious or nervous about treating the child, time constraints, and high dental costs. Non-environmental reasons included the child’s perceived dislike of dental procedures, perceived inability to behave cooperatively during dental visits, complex medical conditions complicating dental treatment, and other more urgent healthcare needs. Facilitators: Better oral health knowledge and more positive oral health attitudes among parents of children with ASD.
Fenning et al., (2020) [65]	Cross-sectional	USA	375 families of children ages 4 to 17	ASD	92% of families reported accessing dental care, with 64.2% obtaining two preventive dental visits, 33.7% reporting one preventive dental visit, and only 2% reporting no preventive dental visits. Families of children on the register were more likely to report a high level of access to dental visits. However, disparities existed in the type of care received, as younger child age and lower levels of child IQ and adaptive behavior were associated with receiving less comprehensive dental care. Moreover, caregiver education found to be positively associated with receiving a greater number of dental services. Study primarily focused on attributing impairments to the children rather than exploring ways to adapt the dental environment to their needs.	Access barriers: Perceived child IQ and behavioral issues. Access facilitators: Caregiver education, oral health education in preventive services.es.
Gerreth et al., (2016) [50]	Cross-sectional	Poland	264 parents/ caregivers	Intellectual Disability	Only 31.8% of parents/caregivers had no access problems to dental care. The primary barrier reported was a protracted waiting time for appointments, affecting 36.7% of respondents. Notably, 90.1% of children were treated in dental surgery conditions. Additionally, only 42.1% of respondents expressed satisfaction with their children’s dental care.	Barriers: Perceived degree of intellectual disability, long waiting time for appointments, dentist reluctance, high costs of dental services, inconvenient opening hours of dental offices, the location of dental surgeries in relation to the patient’s residence, architectural limitations in the dental surgery, and limited access to transport and communication challenges for individuals with more profound intellectual disabilities. Facilitators: Having a milder degree of intellectual disability
Holt & Parry, (2019) [51]	Cross-sectional	UK	Parents/carers of 17 children and young people with autism spectrum conditions	ASD	Time spent in waiting areas can increase anxiety in children and young people with autism spectrum conditions. All parents viewed Real-time Text Messaging as having a positive impact on the dental attendance experience. The majority believed it reduced anxiety and enabled children and young people with autism spectrum conditions to be more accepting of dental treatment	Barriers: Time spent in waiting areas can increase anxiety. Facilitators: Real-time text messaging reduces anxiety and enables acceptance of dental treatment
Hu & Da Silva, (2022) [44]	Cross-sectional	Canada	189 parents or caregivers	Developmental disabilities	Common barriers were cost (63%), location (55%), the child’s behavior (78%) and caregiver anxiety (60%). 35% of caregivers believed their dentist lacked adequate knowledge of Fetal Alcohol Spectrum Disorder. Univariate analysis reveals that income, caregiver education, residence location, and insurance status were significantly associated with reporting barriers.	Barriers: included cost, location of a dentist, and scheduling. Personal barriers involved the child’s anticipated behavior, caregiver anxiety, lack of perceived need, and other health care priorities. Interpersonal barriers included difficulties finding a dentist without a referral, the belief that the dentist lacked adequate knowledge of the child’s condition, feelings of discrimination or disrespect, and the belief that the dentist did not spend enough time with the child. Additionally, income, caregiver education, residence location, and insurance status were significantly associated with reporting barriers. Facilitators: Higher education levels and higher incomes among caregivers aid in accessing oral health care
Junnarkar et al., (2023) [39]	Qualitative	Singapore	23 parents of autistic children	Autism	Accessing dental services was hindered by a lack of parental knowledge on the importance of an early dental home, parental apprehension about the child’s acceptance of dental care, lack of information on specialized dentists and perceived high cost of dental visits	Barriers: Parental knowledge issues, parental attitude and anxiety, dentist-related factors (dentists unwilling to treat persons with ASD, long waiting time to see specialist dentists, lack of information on dentists who can treat persons with ASD), and cost concerns. Facilitators: Providing parents with coping strategies and utilizing techniques such as social stories, visual aids, and pretend play to improve the dental experience for autistic children
Kachwinya et al., (2022) [62]	Cross-sectional	Uganda	90 children and their caregivers.	Cerebral palsy	The most common barrier reported by the caregivers was the challenge in modality of transportation availability from the children’s homes to the health facilities (34.4%).	Barriers: Transportation difficulties, high transportation costs, low income, and a limited perception of the need for regular dental care. Some caregivers believed that dental care was only necessary for specific issues such as swelling, cracked teeth with pain, or mobile teeth, which contributed to a restricted understanding of the importance of regular dental visits. Facilitators: Not mentioned.
Krishnan et al., (2018) [52]	Mixed Methods	India	195 dentists and 100 caregivers, whose children were between 3 and 15 years of age.	Different disabilities	The majority of dentists (83.7%) reported not receiving enough training to handle children with special needs. Caregivers (38%) reported the children’s perceived fear of dentists as a major barrier to utilizing dental services.	Barriers: Inadequate training of dentists, infrastructural limitations in dental clinics, fear of dentists, financial constraints, and a lack of adequate facilities. Facilitators: Positive behavior and understanding demonstrated by dentists, as well as their assistance with transfers between wheelchairs and dental chairs.
Lai et al., (2012) [53]	Cross-sectional	USA	(555) children with ASD / caregivers	ASD	The main barriers were perceived child’s behavior, cost, and lack of insurance. The significant predictor variables of unmet needs were perceived child’s behavior (p = 0.01), child’s dental  health (p\0.001), and caregiver’s last dental visit greater than 6 months ( p = 0.002).	Barriers: Perceived child cooperation, cost of dental care, lack of dental insurance, limited availability of dentists, transportation problems, difficulty in getting appointments, lack of knowledge about where to go for dental care, inconvenient office hours, long wait times in clinics/offices, family and caregiver factors (health of another family member, other family priorities), negative perceptions and trust issues towards dentists, child being too young, language barrier. Facilitators: Promoting positive behavior in children can play a beneficial role in the dental setting.
Liu et al., (2022) [40]	Cross-sectional	Australia	169 carers	Developmental Disabilities	Nearly 25% of the participants found it extremely difficult to obtain appropriate oral health care. Amongst the participants 10% had to abandon dental treatment due to difficulties, while 13% have yet to receive any sort of dental care. Amongst school-aged children, 64.5% were unable to receive dental care from the school dental service	Barriers to accessing dental care: Lack of appropriate dental equipment; difficulties in booking appointments and a poor referral system; limited oral health awareness and knowledge of available services; negative attitude and inadequate knowledge and experience of staff, along with lack of infrastructure; shortages in special needs dentistry specialists. Cost, travel distances, and waiting times; challenges related to wheelchair access; and feelings of discrimination, insecurity, anxiety, and fear reported by patients. Facilitators: Not mentioned
Mansoor et al.,(2018) [54]	Case-control	UAE	parents of 84 ASD and 53 healthy children	ASD	A majority of parents of ASD children (83.3%) reported that their children needed assistance in brushing their teeth, while only 15.4% of parents of healthy controls reported the same. During dental visits, perceived uncooperative behavior, and a significantly higher percentage of parents (37%) rated their child’s experience as negative, compared to 9.5% among parents of control children. The dental visits for autistic children mostly involved extraction	Barriers: Limited availability of dentists who can handle the child’s needs, perceived child uncooperative behavior during dental visits, fear or anxiety experienced by the child towards dental care, and a lack of complaints or perceived dental issues leading to reluctance or avoidance of dental visits. Facilitators: Not mentioned
Nelson et al., (2011) [14]	Cross-sectional	USA	1,128 Parents	CSHCN	Children with craniofacial anomalies had twice as many unmet needs and children with cystic fibrosis had fewer unmet needs. Children with cerebral palsy, autism, developmental delay, and Down syndrome had more perceived aversion to dental treatment, more treatment complications posed by their medical conditions, and more difficulty finding a dentist willing to provide care. Children with cystic fibrosis, metabolic disorders, or hemophilia encountered fewer barriers to care.	Barriers: Environmental and non-environmental barriers to accessing dental care for children include cost constraints, difficulties in finding a dentist willing to treat the child, complicated medical conditions of the child affecting dental treatment, income limitations, perceived child’s fear and anxiety towards dental care, perceived behavioral challenges, and oral healthcare having a lower priority compared to the child’s other healthcare needs. Facilitators: None mentioned.
Parry et al., (2023) [55]	Qualitative	UK	6 parents of 10 children diagnosed with ASD	Autism	Parental perceptions included the need for understanding and training among dental professionals, awareness of sensory issues, recognition of individual autistic traits, clear communication, and factors affecting parental confidence in advocating for their children. Focus group participants emphasized empathizing with autistic perspectives, the importance of positive oral health messages, and the challenges in altering dietary regimes and establishing dental preventive habits for their children	Barriers: Lack of understanding and training, awareness of sensory issues, recognition of the individuality of autistic traits, time and clarity for communication, factors affecting parental confidence in advocating in the clinical environment, lack of understanding regarding altering self-imposed, ritualistic dietary regimes, and difficulty in enacting good dental preventive habits for autistic children. Facilitators for children’s dental care include immersive empathy from oral health team members, visual communication, distraction techniques, tailored information, ASD awareness and training, strategic preparation, autonomy support, addressing sensory challenges, recognizing hidden disabilities, minimizing anticipatory distress, valuing parents’ expertise, adjusting power dynamics, and adapting to changing behaviors.
Puthiyapurayil et al., (2022) [56]	Cross-sectional	India	300 children and their parents	Children with intellectual needs	Predominant barriers for access dental care were financial difficulties (35.3%), lack of knowledge about dental care (24%), transportation difficulties (15%).	Barriers: Financial difficulties, lack of knowledge about dental care, transportation difficulties, lack of trained dentists, perceived uncooperative behavior of children, and dentists not willing to treat. Facilitators: None mentioned.
Rajput et al., (2021) [57]	Cross-sectional	India	600: 300 differently abled children and 300 healthy children	Differently abled children	In the study group, the highest mean scores for barriers observed in the areas of lack of priority care (8.82±2.81), difficulty in communicating with the dentist (7.85±1.92), high treatment cost (6.90±1.98), and fear of dental instruments (6.90±1.98). Conversely, in the control group, the main barriers related to affordability and perceived fear. Additionally, deficiencies found in dental clinic facilities, specifically the absence of wheelchairs (76.3% and 76.7%) and corridor signs (66.3% and 61.7%)	Barriers: Lack of dental awareness among parents, lack of priority care, communication challenges, high treatment costs, fear-related concerns, inadequate clinic infrastructure, limited access due to scarcity of nearby dentists, insufficient time for visits, high travel costs, and time-consuming appointments. Facilitators for dental care utilization include increased awareness, treatment availability, accessibility, effective communication, priority care, addressing fear, and improving facilities in dental clinics.
Sabbarwal et al., (2018) [43]	Cross‑sectional	India	100 DS children, 100 non‑DS and their parents/ caregivers	DS	DS children had poor oral hygiene and considerable caries experience and faced certain barriers to utilization of oral health care services.	Barriers: the presence of medical conditions, the cost of dental treatment, and dentist-related factors. Facilitators: Parental awareness of dental problems positively influenced the utilization of oral health services.
Schultz et al., (2001) [34]	Cross-sectional	USA	12,539 children ages 2–17 years for the study population.	Developmentally disabled children	Parental perception of unmet need was significantly associated with developmentally disabled children 2-17 years in lower socioeconomic groups.	Barriers: Children from lower socioeconomic groups who are eligible for Medicaid coverage face cost barriers to accessing dental care. Additionally, children with developmental disabilities encounter perceived barriers to care that influenced by family income levels. Facilitators: Lack of income-related barriers to dental care access
Shyama et al., (2015) [58]	Cross-sectional	Kuwait	308 parents of children with disabilities + teachers, who had normal children (n = 112)	Physical disability & DS	Perceived barriers to dental care for children with disabilities and typically developing children include difficulty in getting appointments, reported by 37.3% of parents. Parents of disabled children consider difficulty in cooperation as a more important barrier to treatment (34.7%) compared to parents of typically developing children (20.3%). A larger proportion of parents of typically developing children (82%) rate the present dental services as excellent/good, compared to 52% of parents of disabled children (p < 0.001). Toothache and curative treatment needs are the main reasons for dental visits among disabled children.	Barriers: Difficulty in getting an appointment, perceived challenges with cooperation, distance and transportation challenges, and cost. Facilitators to dental care access for children include higher dental visits, early dental check-ups, and availability of government dental clinics, and positive perceptions of dental services.
Stein et al., (2012) [59]	Cross-sectional	California (USA)	396 parents of ASD children or typically developing	ASD	Significantly more parents of ASD children than parents of typically developing children reported difficulty across almost all oral care variables explored, including oral care in the home, oral care at the dentist, and access to oral care.	Barriers: Negative experiences, sensory sensitivities, perceived uncooperative behaviors, and difficulties in finding accommodating dental providers. Facilitators: Parental persistence, the availability of dental care, and supportive dental professionals who are trained to work with children with special health care needs.
Zahran et al., (2023) [66]	Cross-sectional	KSA	602 caregivers	Children with autistic spectrum disorder (ASD), Down syndrome, cerebral palsy, and developmental delay	The most common reported barrier was fear of the dentist (61.6%) followed by child uncooperativeness (37.8%) and treatment costs (27.8%).	Barriers: larger family size, low income, low education levels, fear of the dentist, child uncooperativeness, and treatment costs. Facilitators: Caregivers with higher education levels and smaller family sizes
Zhou et al., (2021) [63]	Cross-sectional	Hong Kong, China	383 children	Children with special education needs (SEN)(children were diagnosed with cerebral palsy, intellectual disabilities, autism, developmental delay, Down syndrome, Williams syndrome, or other specific syndromes)	Most parents (72.3%) faced challenges with dental visits for their children, citing barriers such as high cost (33.2%) and perceived children’s aversion to mouth procedures (58.1%). A small percentage of parents (1.4%) also reported sensitivity to sound and light as an additional barrier.	Barriers: The environmental barriers to accessing dental care included high dental costs, difficulty finding a dentist willing to treat the child due to their medical condition, and the challenge of finding a dentist near their home. Non-environmental barriers included the child’s perceived resistance to dental procedures, perceived inability to behave cooperatively during dental visits, being too young for dental appointments, fear of the dentist, and parental anxiety. Facilitators: Children’s age and parents’ education attainment can act as facilitators to dental care access.
Zickafoose et al., (2015) [67]	Cross-sectional	USA	Parents of 2055 children with special health care needs	CSHCN	The Children’s Health Insurance Program (CHIP) demonstrates greater access to dental services for children with special health care needs (CSHCN) and their families compared to uninsured children and their families.	Barriers: There were large differences in access to and use of dental services. Lack of insurance coverage or inadequate private policies did not sufficiently cover dental services for children with additional needs. Facilitator: The Children’s Health Insurance Program (CHIP) provides access to dental care for children with additional needs

Key: ASD Autism Spectrum Disorders, DS Down Syndrome, CSHCN Children with special health care needs