The goal of this research project is to collect information that will support a later clinical trial on the effectiveness of a specially adapted dental environment for children who have difficulty tolerating oral care in the dental clinic. Within this project, two groups of children will be studied: children with autism spectrum disorders (ASD) and typically developing children, including those who are over-reactive to sensory stimulation. Commonly, such children exhibit anxiety and negative behavioral reactions when confronted with experiential aspects of dental visits such as exposure to bright fluorescent lighting, touch in or around the mouth, or the texture and smell of various oral care products. In the grant, we will pilot test a sensory adapted dental environment (SADE) that has a strong potential to reduce anxiety and behavioral problems among the targeted groups of children. The SADE intervention includes such adaptations as dimmed lighting, exposure to soothing music, and application of a special vest which provides deep pressure sensations that are calming. If our preliminary assessment produces promising results, we later plan to more comprehensively test the intervention in a full-scale randomized clinical trial.
Research participants will be 40 ethnically diverse children aged 6-12 years, 20 with ASD and 20 who are typically developing. Each child will undergo two dental cleanings four months apart: dental cleaning in a standard dental environment, and dental cleaning in the sensory adapted environment. For each group of children (i.e., ASD and typically developing), the two conditions will be compared in their effects on anxiety and negative behavioral reactions, as measured by videotape coding, psychophysiological indices, and various rating scales.
Because the planned research will contribute to safer, more efficient, less costly treatment, it has the potential to revolutionize clinic-based dental care for the growing population of children with ASD, as well as for typically developing children who have dental anxieties. The potential cost-savings and contribution to child comfort are dramatic, as potentially more than one-fourth of all children may benefit.
Journal Articles
Stein Duker, L. I., Henwood, B. F., Bluthenthal, R. N., Juhlin, E., Polido, J. C., & Cermak, S. A. (2017). Parents’ perceptions of dental care challenges in male children with autism spectrum disorder: An initial qualitative exploration. Research in Autism Spectrum Disorders, 39, 63-72. https://doi.org/10.1016/j.rasd.2017.03.002 Show abstract
Background. Many children with autism spectrum disorders (ASD) experience barriers to oral care in the dental office setting. The purpose of this study was to provide an increased understanding of these challenges experienced during oral care in the dental office by children with ASD.
Method. This study was part of a larger mixed methods design and builds on quantitative results from a survey of parents of children with ASD ages 2–18 in which parents reported difficulties with access to care, sensory processing, and uncooperative behaviors. For this study, we conducted two, three hour, focus groups of parents of male children with ASD age 5–18 years in order to explore the survey results in greater depth. Focus group transcripts were analyzed using a template coding approach based on the three domains of office-based oral care challenges identified in the first phase (survey).
Results. Several related themes emerged including: (1) Access: “Difficult to find the right dentist”, (2) Sensory sensitivities: “All the sensory devices just make him so uncomfortable”, (3) Restraint: “It looked like they were torturing him”, and (4) Drugs: “A mixed bag”.
Conclusions. The qualitative findings from this study both confirmed our previous survey findings and expanded upon them. These findings can help professionals better understand the challenges experienced by children with ASD and their parents as well as help identify priorities for planning efforts to address the oral health-related needs of this population.
Cermak, S. A., Stein Duker, L. I., Williams, M. E., Dawson, M. E., Lane, C. J., & Polido, J. C. (2015). Sensory adapted dental environments to enhance oral care for children with autism spectrum disorders: A randomized controlled pilot study. Journal of Autism and Developmental Disorders, 45(9), 2876-2888. https://doi.org/10.1007/s10803-015-2450-5 Show abstract
This pilot and feasibility study examined the impact of a sensory adapted dental environment (SADE) to reduce distress, sensory discomfort, and perception of pain during oral prophylaxis for children with autism spectrum disorder (ASD). Participants were 44 children ages 6-12 (n = 22 typical, n = 22 ASD). In an experimental crossover design, each participant underwent two professional dental cleanings, one in a regular dental environment (RDE) and one in a SADE, administered in a randomized and counterbalanced order 3-4 months apart. Outcomes included measures of physiological anxiety, behavioral distress, pain intensity, and sensory discomfort. Both groups exhibited decreased physiological anxiety and reported lower pain and sensory discomfort in the SADE condition compared to RDE, indicating a beneficial effect of the SADE.
Cermak, S. A., Stein Duker, L. I., Williams, M. E., Lane, C. J., Dawson, M. E., Borreson, A. E., & Polido, J. C. (2015). Feasibility of a sensory-adapted dental environment for children with autism. American Journal of Occupational Therapy, 69(3), 6903220020p1-6903220020p10. https://doi.org/10.5014/ajot.2015.013714 Show abstract
Objective. To provide an example of an occupational therapy feasibility study and evaluate the implementation of a randomized controlled pilot and feasibility trial examining the impact of a sensory-adapted dental environment (SADE) to enhance oral care for children with autism spectrum disorder (ASD).
Method. Twenty-two children with ASD and 22 typically developing children, ages 6-12 yr, attended a dental clinic in an urban hospital. Participants completed two dental cleanings, 3-4 mo apart, one in a regular environment and one in a SADE. Feasibility outcome measures were recruitment, retention, accrual, dropout, and protocol adherence. Intervention outcome measures were physiological stress, behavioral distress, pain, and cost.
Results. We successfully recruited and retained participants. Parents expressed satisfaction with research study participation. Dentists stated that the intervention could be incorporated in normal practice. Intervention outcome measures favored the SADE condition.
Conclusion. Preliminary positive benefit of SADE in children with ASD warrants moving forward with a large-scale clinical trial.
Chaspari, T., Tsiartas, A., Stein, L. I., Cermak, S. A., & Narayanan, S. S. (2015). Sparse representation of electrodermal activity with knowledge-driven dictionaries. IEEE Transactions on Bio-Medical Engineering, 62(3), 960-971. https://doi.org/10.1109/TBME.2014.2376960 Show abstract
Biometric sensors and portable devices are being increasingly embedded into our everyday life, creating the need for robust physiological models that efficiently represent, analyze, and interpret the acquired signals. We propose a knowledge-driven method to represent electrodermal activity (EDA), a psychophysiological signal linked to stress, affect, and cognitive processing. We build EDA-specific dictionaries that accurately model both the slow varying tonic part and the signal fluctuations, called skin conductance responses (SCR), and use greedy sparse representation techniques to decompose the signal into a small number of atoms from the dictionary. Quantitative evaluation of our method considers signal reconstruction, compression rate, and information retrieval measures, that capture the ability of the model to incorporate the main signal characteristics, such as SCR occurrences. Compared to previous studies fitting a predetermined structure to the signal, results indicate that our approach provides benefits across all aforementioned criteria. This paper demonstrates the ability of appropriate dictionaries along with sparse decomposition methods to reliably represent EDA signals and provides a foundation for automatic measurement of SCR characteristics and the extraction of meaningful EDA features.
Stein, L. I., Lane, C. J., Williams, M. E., Dawson, M. E., Polido, J. C., & Cermak, S. A. (2014). Physiological and behavioral stress and anxiety in children with autism spectrum disorders during routine oral care. BioMed Research International, 2014, 694876. https://doi.org/10.1155/2014/694876 Show abstract
Background. Children with autism spectrum disorders (ASD) commonly exhibit uncooperative behaviors which impede oral care. Previous studies have utilized dentist-report measures of uncooperative behaviors in children with ASD but none have utilized an objective measure of children's behavior or a physiological measure of distress. This study investigated behavioral and physiological distress in children with ASD during routine oral care and examined factors associated with this distress.
Methods. Participants were 44 children (typical, ASD) aged 6-12 receiving routine dental cleanings. Behavioral and physiological measures of stress and anxiety were collected during dental cleaning.
Results. Children with ASD exhibited greater distress, compared to the typical group, on dentist-report and researcher-coded measures of overt distress behaviors and on physiological measures. Correlations between physiological and behavioral measures of distress were found in the ASD but not in the typical group. Behavioral distress was correlated with age in the typical group and with expressive communication ability and sensory processing difficulties in the ASD group; physiological distress was correlated with parent-report of anxiety in the typical group and sensory processing difficulties in the ASD group.
Conclusions. Novel strategies may be required to decrease behavioral and physiological distress in children with ASD in the dental clinic.
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