Sensory Adaptations to Improve Physiological and Behavioral Distress During Dental Visits in Autistic Children: A Randomized Crossover Trial
Open accessAbstract
Importance: Autistic children have poorer oral health and greater oral care challenges, which are often associated with sensory overresponsivity, than neurotypical peers. It is important to identify innovative solutions enabling dentists to successfully perform standard clinic-based procedures for this population. Objective: To determine whether a sensory-adapted dental environment (SADE) reduces physiological and behavioral distress in autistic children undergoing dental cleanings, compared with a regular dental environment (RDE). Design, Setting, and Participants: This randomized crossover trial was conducted at a pediatric dentistry clinic in a large urban children’s hospital between May 2016 and April 2022. Coders were blinded to study condition for physiological but not behavioral measurements. Autistic children aged 6 to 12 years were identified and invited to participate. Interested families were enrolled consecutively; after confirmation of autism diagnosis, children were randomized. Analysis for this per-protocol study were conducted from April to October 2022. Intervention: Each child underwent 1 RDE and 1 SADE dental cleaning, administered in randomized and counterbalanced order approximately 6 months apart. SADE included modified visual, auditory, and tactile stimuli. Main Outcomes and Measures: The primary outcome was physiological stress, assessed by electrodermal activity. The secondary outcome was behavioral distress measured from video recordings. Results: Among 452 families invited to participate, 220 children were enrolled, and 162 children (mean [SD] age, 9.16 [1.99] years; 136 [84.0%] male) with confirmed autism were randomized, with 83 children receiving RDE first and 80 children receiving SADE first. Most children (94 children [58.0%]) had moderate autism severity. Children had significantly lower physiological stress during dental care in SADE compared with RDE (mean difference in skin conductance level, −1.22 [95% CI, −2.17 to −0.27] μS), suggesting decreased sympathetic activity and increased relaxation during SADE dental care. No significant differences were found in nonspecific skin conductance responses (mean difference, −0.30 [95% CI, −0.86 to 0.25] per min). Video-coded frequency and duration of behavioral distress (but not questionnaire) measures were significantly lower in SADE vs RDE (Cohen d = −0.84 to −1.19). Physiological stress was associated with behavioral distress during the dental cleaning (eg, nonspecific skin conductance responses associated with the Frankl Scale: β = −0.29; 95% CI, −0.39 to −0.19); age, IQ, and expressive communication moderated the intervention’s success. No participants withdrew due to adverse effects. Conclusions and Relevance: In this randomized crossover trial of autistic children, using SADE was safe and efficacious in decreasing physiological and behavioral distress during dental care. This is important because enhancing oral care is critical for autistic children; this intervention may also be beneficial for populations beyond autism. Trial Registration: ClinicalTrials.gov Identifier: NCT02430051
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Structured visual and staged behavioral approaches improve compliance with examination steps and cooperation, with measurable improvements using cooperation scales in clinical settings.
“Structured visual and staged behavioral approaches have also been applied to improve compliance with examination steps and cooperation, with measurable improvements using cooperation scales in clinical settings.5”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Results (Secondary Outcomes; page unavailable) report less frequent and shorter distress behaviors in the sensory-adapted dental environment, but no significant differences on the behavior scales. The Discussion (page unavailable) explicitly says there were no significant changes on the CDBRS, Frankl Scale, or Anxiety and Cooperation Scale. The Methods describe sensory modifications and a preparatory social story, not a tested staged behavioral approach that improved compliance with examination steps. (LLM, conf=0.88)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredThis review highlights an autism spectrum disorder-dominant evidence base, with limited representation of other neurodevelopmental disorder profiles such as tic disorders, dyslexia, and speech-language delay.
“This review also highlights an ASD-dominant evidence based, with limited representation of other NDD profiles, such as tic disorders, dyslexia, and speech-language delay, in recent chairside management research.2,4,5,7,9”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Methods (Recruitment and Enrollment; page unavailable) required a confirmed autism diagnosis, so this chairside dental study exemplifies an ASD-focused evidence base. The Results (page unavailable) list two children with dyslexia among the 162 participants, but the paper does not establish how well tic disorders, dyslexia, or speech-language delay are represented across recent chairside management research. (LLM, conf=0.84)
Experimental — accuracy not yet measuredAcross the included studies, outcomes included cooperation scales such as the Frankl scale, procedural tolerance or step completion, observed distress coding, and physiological markers including vital signs or electrodermal activity.
“Across the included studies, outcomes included cooperation scales, such as the Frankl scale, procedural tolerance or step completion, observed distress coding, and physiological markers, including vital signs or electrodermal activity.4–7”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Methods > Outcome Measures section reports electrodermal activity and video-coded distress, and the Discussion identifies the Frankl Scale as a measure used in this study. Our copy does not identify procedural tolerance or step completion as an outcome; the completion figures in Results concern study participation, not procedural steps. No page numbers are available in the indexed passages. (LLM, conf=0.84)
Experimental — accuracy not yet measuredWithin the recent evidence base, the literature was limited, predominantly focused on autism spectrum disorder, and highly heterogeneous in interventions and outcome measures.
“Within this recent evidence base, the literature was limited, predominantly focused on ASD, and highly heterogeneous in terms of interventions and outcome measures.2,4–7”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Introduction says there are minimal clinical dental protocols for autistic children and describes several pilot studies, supporting the characterization of this area as limited. This trial focuses on autistic children, but the paper does not establish that the recent evidence base is predominantly ASD-focused or highly heterogeneous in interventions and outcome measures. The indexed passages provide section labels but no page numbers. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThis review provides a systematic overview of recent chairside approach clusters, highlights measurement gaps, and identifies priorities for future work.
“Nevertheless, this review provides a systematic overview of recent chairside approach clusters, highlights measurement gaps, and identifies priorities for future work.1–5,7”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Methods (Study Overview) identify the cited paper as a randomized crossover trial, not a systematic overview of chairside approaches. Its Discussion and Limitations identify future research priorities and limitations in outcome measurement, but they do not establish what the citing review itself provides or survey approach clusters. (LLM, conf=0.82)
Experimental — accuracy not yet measured
The available evidence suggests that non-pharmacological chairside management in neurodevelopmental disorders may be most useful when implemented as a stepwise, patient-centered approach.
“The available evidence suggests that non-pharmacological chairside management in NDD may be most useful when implemented as a stepwise, patient-centered approach.2,4–7”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Methods > Procedures section describes non-pharmacological dental adaptations chosen in part by the child or parent and discontinued if they caused discomfort. The Conclusions report reduced distress during routine cleanings in autistic children. The paper does not establish that a stepwise approach is most useful, or test this approach across neurodevelopmental disorders more broadly; the Discussion identifies further tailoring and other populations as topics for future research. Page numbers were not provided in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measuredSensory adaptation of the dental environment provides a concrete clinic-level strategy to reduce physiological stress and observed distress during routine care, particularly for children with sensory over-responsivity.
“Third, sensory adaptation of the dental environment provides a concrete clinic-level strategy to reduce physiological stress and observed distress during routine care, particularly for children with sensory over-responsivity.5”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Abstract Findings and Results > Secondary Outcomes report lower physiological stress and less frequent and shorter observed distress behaviors during sensory-adapted dental cleanings for autistic children, though not all behavioral measures differed. The claim’s emphasis on children with sensory over-responsivity is not supported: Results > Moderation Analysis found no such moderation of physiological stress and reported greater behavioral benefit among children with lower sensory over-responsivity. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIn a large randomized crossover trial involving autistic children, a sensory-adapted dental environment significantly reduced physiological stress and observed behavioral distress compared with a regular dental environment during routine dental cleaning.
“In a large randomized crossover trial involving autistic children, a sensory-adapted dental environment (SADE) significantly reduced physiological stress and observed behavioral distress compared with a regular dental environment during routine dental cleaning.”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
Moderators such as age, IQ, and expressive communication influenced intervention success in the sensory-adapted dental environment trial.
“Moderators such as age, IQ, and expressive communication influenced intervention success.”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The influence of moderators suggests that a one-size-fits-all sensory adaptation may not be equally effective across the autism spectrum.
“This suggests that a one-size-fits-all sensory adaptation may not be equally effective across the ASD spectrum.5”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
Protective stabilization was discussed or employed in selected circumstances during treatment.
“Protective stabilization was also discussed or employed in selected circumstances during treatment.2,4–7”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Methods (Procedures; page not provided) describe a butterfly wrap used to provide calming deep pressure during dental cleanings, not protective stabilization. The Results (Intervention Fidelity; page not provided) report how often the wrap was used, but neither passage establishes that protective stabilization was discussed or employed. Searches for “protective stabilization” and restraint found no passage addressing that practice. (LLM, conf=0.74)
Experimental — accuracy not yet measuredThe supporting evidence was heterogeneous in design and outcome measures, making quantitative synthesis impossible.
“Furthermore, the supporting evidence was heterogeneous in design and outcome measures, making quantitative synthesis impossible.2,5”
From Adapting the Chairside: Pediatric Dental Management for Children with Neurodevelopmental Disorders – A Scoping Review (2026) · cites this paper as [5]
The Methods (Statistical Analysis; page unavailable) describe quantitative analyses of this trial, not a synthesis of multiple studies. The Discussion compares some outcome measures used in earlier studies, but does not say that differences in study design or measures made quantitative synthesis impossible. Searches for heterogeneity, pooling, and meta-analysis found no passage addressing that claim. (LLM, conf=0.75)
Experimental — accuracy not yet measured
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Cites
Publication recommendations for electrodermal measurements
Society for Psychophysiological Research Ad Hoc Committee on Electrodermal Measures (2012) · Psychophysiology · doi:10.1111/j.1469-8986.2012.01384.x · Cited by 1,288 · see citing works
Peters, S. A. E., Bots, M. L., den Ruijter, H. M., Palmer, M. K., Grobbee, D. E., Crouse, J. R., O’Leary, D. H., Evans, G. W., Raichlen, J. S., Moons, K. G. M., et al. (2012) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2011.11.012 · Cited by 165 · see citing works
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Cited by
Sorted by citations
Swastiantari, P. A., Primarti, R., Ahmad M, I., Andisetyanto, P., & Pratidina, N. (2026) · Clinical, Cosmetic and Investigational Dentistry · doi:10.2147/ccide.s605432
- Authors
- Stein Duker, L. I., Como, D. H., Jolette, C., Vigen, C., Gong, C. L., Williams, M. E., Polido, J. C., Floríndez-Cox, L. I., & Cermak, S. A.
- Affiliations
- Division of Occupational Science and Occupational Therapy at the Ostrow School of Dentistry, University of Southern California, Los Angeles
- University of Southern California (US)
- ORCID
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2023-06-02
- Volume
- 6
- Issue
- 6
- Pages
- e2316346
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC10238943
- OpenAlex
- W4379094570
- Cited by
- 46
- References
- 2
- Citations by year
- 2026: 27 · 2025: 5 · 2024: 10 · 2023: 4
- FWCI
- 11.73
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- University of Southern California
- National Institute of Dental and Craniofacial Research (F31DE030006, U01DE024978, T90DE021982)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (K12HD055929)
- National Center for Medical Rehabilitation Research (K12 HD005929)
- Topics
- Health Sciences › Dentistry › Oral Surgery › Dental Anxiety and Anesthesia Techniques
- Health Sciences › Dentistry › Periodontics › Dental Health and Care Utilization
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Keywords
- autism spectrum disorder, pediatric dental care, dental anxiety, physiological stress, skin conductance, behavioral distress, sensory hypersensitivity, dental cleaning, oral health
- MeSH terms
- Autistic Disorder, Child, Female, Humans, Male, Cross-Over Studies
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