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. 2021 Jan 18;18(2):789. doi: 10.3390/ijerph18020789

Table 3.

Main characteristics of the included studies regarding ASD children’s behavior during dental care procedures.

Author (Year) N-Sunjects M/F Age-Range Intellectual Disability/Verbal Fluency Study Length Type of Tool Visual Pedagogy Protocol Adjunctive Tool Study Design/Groups (Outcome) Dental Visit Results Mean (SD) or Counts Findings
PECS
Zink et al. (2018) [23] 40 - - Images (digital) or PECS (paper) Provided once by dentist BM Two Groups: G1 G2 The mean number of attempts for acquiring each step (p < 0.01) and number of visits to fully cooperate (p < 0.01) were significantly lower in G1 compared to G2
M/F G1: app on iPad® (n = 20) Mean number of attempts (n) *
9–15 yy G2: PECS (n = 20) Step One 1.1 (0.3) 1.5 (0.8)
Step Two 1.1 (0.5) 1.6 (0.6)
Professional teeth-cleaning, divided in seven steps, reported as the number of attempts for acquiring each step and number of visits to fully cooperate Step Three 1.5 (0.5) 1.6 (0.7)
Step Four 1.0 (0.2) 1.7 (1.1)
Step Five 1.2 (0.4) 1.6 (0.9)
Step Six 1.2 (0.6) 1.8 (0.9)
Step Seven 2.1 (0.9) 2.6 (1.7)
Number of visits (n) *
3.0 (1.0) 4.3 (1.2)
Hidayatullah et al. (2018) [26] 13 From mild to moderate One mo PECS (paper) Provided weekly by teacher and by dentist BM One group (n = 13) Mean number of steps completed (n) † Patients were able to perform more steps within a dental visit at one-, two-, three-, and four-week evaluations (p < 0.01)
M/F One wk 1.9 (1.3)
5–18 yy Dental visit divided into 10 steps Two wk 3.5 (0.9)
Three wk 4.5 (1.7)
Four wk 5.6 (1.9)
Zink et al. (2016) [35] 26 - - PECS (paper) Provided once by the dentist BM Two groups G1 G2 The mean number of attempts required for steps two, four, five, and six were significantly lower (p < 0.05) in G1 compared to G2
M/F G1: no dental experience (n = 13) Mean number of attempts (n) *
5–19 yy
M/F G2: previous dental experience (n = 13) Step One 1.8 (1.0) 1 2.8 (1.6)
Step Two 1.5 (1.5) 2.5 (1.9)
Step Three 2.8 (1.6) 4.4 (2.5)
Dental visit divided into six steps, and professional teeth-cleaning (including fluoride therapy), considered as step seven, reported as the number of attempts for acquiring each step Step Four 2.0 (1.9) 3.4 (2.1)
Step Five 2.1 (1.7) 4.6 (2.1)
Step Six 2.5 (2.1) 4.4 (1.7)
Step Seven 3.8 (3.3) 4.6 (2.4)
Mah and Tsang, (2016) [29] 14 Mild Three wk PECS (paper) Provided weekly by dentist/hygienist TSD Two groups G1 G2 The mean number of steps completed increased, completion time decreased, and anxiety decreased more in G1 compared to G2 at one-, two-, and three- week evaluations (no statistical analysis available)
M G1: test group (n = 7) Mean number of steps completed (n)
4–8 yy G2: control group (n = 7) Baseline 8.91 (2.04) 7.95 (2.04)
One wk 10.12 (1.81) 8.31 (1.81)
Dental visit, divided into seven steps, and professional teeth-cleaning, divided in the following five steps, reported as the number of steps completed at each visit and time to perform them Two wk 10.54 (1.68) 9.17 (1.68)
Three wk 11.48 (1.28) 10.09 (1.28)
Completion time per step (min)
Baseline 1.41 (0.47) 7.95 (2.04)
One wk 1.04 (0.35) 8.31 (1.81)
Two wk 1.00 (0.43) 9.17 (1.68)
Three wk 0.98 (0.45) 10.09 (1.28)
Anxiety Likert Scale Score
Baseline 1.55 (0.48) 2.48 (0.48)
One wk 1.62 (0.45) 2.14 (0.45)
Two wk 1.77 (0.57) 2.15 (0.57)
Three wk 1.65 (0.54) 2.08 (0.54)
Bossù et al. (2014) [25] 34 - Three yy PECS (paper) Provided once by the dentist TSD, desensitization One group (n = 34) Cooperative patients (n) The majority of children were cooperative during dental procedures (no statistical analysis available)
M/F Tooth extraction 2/2
6–12 yy Number of cooperative patients during preventive, restorative, and surgical procedures Tooth Filling 8/10
Oral hygiene 30/34
Dental sealant 18/28
Different Kind of Images
Lefer et al. (2019) [28] 52 From mild to severe Eight mo Photos (digital) Provided at weekdays by teacher - One group (n = 52) Global Skill acquisition Score * Both scores significantly improved at two-, four-, six-, and eight-month evaluations (p < 0.01) compared to baseline
M/F Baseline 2.3 (0.6)
3–19 yy Dental visit, divided into six steps, reported as a score from 1 to 3 (1 = not acquired; 2 = emerging; 3 = acquired), and behavior assessment (Frankl Behavior Score) Two mo 2.5 (0.5)
Four mo 2.7 (0.5)
Six mo 2.7 (0.4)
Eight mo 2.8 (0.6)
Frankl Behavior Score *
Baseline 2.7 (0.8)
Two mo 3.2 (0.9)
Four mo 3.3 (1.0)
Six mo 3.4 (0.8)
Eight mo 3.4 (0.9)
Murshid E. Z. (2017) [30] 40 - Six mo Dental book (Paper) Provided daily by parents - One Group (n = 40) Cooperative patients (%) * Children’s behavior significantly improved at a four-month evaluation (p < 0.01)
M/F One wk
5–9 yy Dental visit, professional teeth-cleaning, and fluoride therapy, reported as the number of patients for each behavior score (Frankl Behavior Score) Definitely positive 0
Positive 47.5
Negative 32.5
Definitely negative 20.0
Four mo
Definitely positive 0
Positive 80.0
Negative 12.5
Definitely negative 7.5
Nilchian et al. (2017) [31] 40 From mild to moderate Two mo Coloring pictures (Paper) Provided twice a day by a trained teacher - Two Groups: G1 G2 Number of cooperative patients increased significantly at two-, four-, six-, and eight-week evaluations in both groups (p < 0.01) and at eight weeks during fluoride therapy only in G1 (p < 0.01). No further inter-group differences were found
M/F G1: case group (n = 20) Cooperative patients (%)
6–12 yy G2: control group (n = 20) Dental visit
Baseline 15 15
Number of cooperative patients during dental visit and fluoride therapy Two wk 30 15
Four wk 40 25
Six wk 50 55
Eight wk 70 65
Fluoride therapy
Baseline 0 0
Two wk 0 0
Four wk 0 0
Six wk 5 0
Eight wk 30 5
Cagetti et al. (2015) [4] 83 From mild to severe One and a half mo Coloring pictures (digital) Provided twice a week by psychologist, then daily by parents - One group (n = 83) Cooperative patients (n) The majority of children were cooperative (no statistical analysis available).
Cooperation was statistically significantly influenced by the child’s verbal fluency in all treatments (p ranging from 0.04 to 0.01) and by intellectual disability in restorative treatment (p = 0.04)
M/F Number of cooperative patients during dental visit and preventive and restorative treatments Oral examination 77/83
6–12 yy Teeth-cleaning 77/77
Sealant 70/77
Restoration 41/44
Schindel et al. (2014) [34] 16 - Two wk Photos (Paper) Provided twice a day by a trained teacher TSD One group (n = 20) Mean number of steps completed (n) † The mean number of steps completed increased and time required per step decreased at a two-week evaluation in all children except one.
M/F Baseline 6.37 (5.10)
10–23 yy
Orthodontic examination, divided into 13 steps, reported as the number of steps completed and time to perform them. Two wk 11.12 (4.18)
Mean completion time (min) †
Baseline 18.78 (7.08)
Two wk 11.54 (4.58)
Bäckman and Pilebro, (1999) [24] 32 From mild to severe 18 mo Dental book (Paper) Provided once or more by parents - Two groups: G1 G2 Children in G1 were more cooperative compared to G2 (no statistical analysis available)
M/F G1: visual pedagogy (n = 16) Number of cooperative patients (n)
3–6 yy G2: control group (n = 16) Dental visit 11 4
Fluoride therapy 2 0
Number of cooperative patients during dental visit, tooth-cleaning, and fluoride therapy Teeth-cleaning 4 0
Video or Video + Images
Orellana et al. (2019) [32] 74 From moderate to severe - Video Provided weekly by dentist TSD, BM, PM 2 groups: G1 G2 The mean number of steps completed increased (p < 0.01) and the children’s behavior improved (p < 0.01) at a seven-week evaluation and was maintained after one month.
M/F G1: 4–9 yy group (n = 52) Mean number of steps completed (n) *
4–17 yy G2: 10–17 yy group (n = 22) Baseline 3.9 (2.7) 4.4 (2.6)
One mo 9.4 (1.5) 9.5 (1.7)
Dental visit, divided in 10 steps, reported as the number of steps completed and behavior assessment (Frankl Behavior Score) Frankl Behavior Score *
Baseline 1.9 (0.8) 2.0 (0.8)
One mo 3.3 (0.8) 3.5 (0.7)
Isong et al. (2014) [27] 80 From mild to moderate Six mo Video Once or more at the home with parents - Four groups: G1 G2 G3 G4 Anxiety and behavior scores statistically significantly decreased at a six-month evaluation in G3 and G4 (p < 0.05).
M/F G1: control group (n = 20) Venham Behavior Scale *
7–17 yy G2: video peer model (n = 20) Baseline 2.2 (1.9) 2.7 (1.8) 2.5 (1.6) 2.9 (1.5)
G3: video googles (n = 20) Six mo 2.3 (1.6) 2.9 (2.0) 1.7 (1.9) 2.1 (1.6)
G4: video model + goggles (n = 20) Venham Anxiety Scale *
Baseline 2.4 (1.8) 2.6 (1.8) 2.6 (1.3) 2.9 (1.3)
Dental visit, reported as a behavior and anxiety assessment (Venham scores) Six mo 2.3 (1.6) 2.6 (1.9) 1.7 (1.8) 2.1 (1.6)
Orellana et al. (2014) [33] 38 From mild to severe Four wk Images (paper) and video Provided twice a week by dentist TSD, desensitization, and modelling 1 group (n = 38) Mean number of steps completed (n) † The mean number of steps completed statistically significantly increased (p < 0.01) and children’s behavior improved (p < 0.01) at a four-week evaluation. Improvements were observed in high-functioning children as well as children with mild and severe disability.
M/F Baseline 3.03 (2.22)
4–10 yy Dental visit, divided into 10 steps, reported as the number of steps completed and behavior assessment (Frankl Behavior Score) Four wk 9.03 (2.05)
Frankl Behavior Score *
Baseline 1.95 (0.77)
Four wk 3.24 (0.88)

yy: Years; mo: months; wk: weeks; M: male; F: female; PECS: Picture Exchange Communication System; TSD: tell-show-do; BM: behavioral management; PM: peer modelling; min: minutes; * results rounded to one decimal; † mean and standard deviation calculated by reviewers when raw data available.