Globally, around 650 million individuals are affected with disabilities which are advancing with the increasing population. According to the reports of the United Nations Development Programme in 2006, about 80% of people having disabilities reside in developing countries, with India being the world's largest populated country with children at high risk of developmental disabilities. Among these, intellectual disability is a condition that is associated significantly with subaverage intellectual development from birth to early childhood. These children have a higher prevalence of poor oral hygiene, which was suggested to be the predominant cause of periodontal disease among them.
Even today, various barriers exist regarding the dental needs of these patients. A majority of studies cited the most common causes of dentist's negligence to provide dental care for them are patient behavior, the severity of dental disease, associated disability, and inadequate training and experience.
Children's anxiety about dental treatment is one such major barrier, which poses a great challenge and can make them avoid dental appointments.
In the regular dental setup, disabled children are sensitive and easily invoked to sensory stimuli such as high-speed handpiece, overhead light, loud ambient noises, texture, and taste of prophylaxis paste. Furthermore, Fallea et al. in 2016 reported that children presenting with ID had unusual reactions to sensory stimuli.
This altered neurophysiological predisposition of individuals with developmental disabilities encountered in regular dental setup could negatively impact their behavior and level of cooperation, making it more difficult for dentists to provide treatment.
Sensory-based treatment has been researched in the dental field as a novel technique to reduce dental anxiety in children. They aim to promote sensory processing and self-regulation, boost adaptive function, and modulate responses to external stimuli. The sensory-adapted dental environment (SADE) comprises a specialized room with controlled multisensory stimuli that is partially lighted, with relaxing music.
The rationale of the present study was to investigate the effectiveness of SADE as a novel, noninvasive behavior management technique. As there is a lack of literature regarding the use of SADE based on the Snoezelen environment and camouflaging instruments during oral prophylaxis in children with mild intellectual disability, the present study aimed to compare and evaluate the effect of SADE and regular dental environment in reducing anxiety levels in children with mild intellectual disability.
Materials and Methods
The present in vivo, randomized clinical trial was conducted with 24 children having a mild intellectual disability with an age range of 8–13 years for oral prophylaxis in the Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere. The study was approved by the Ethical Committee (Ref. No. BDC/Exam/509/2019–20) from the Institutional Review Board, and written informed consent was taken from the legal guardian/caretaker of patients willing to participate in the study after explaining the whole procedure. The study was carried out by a single examiner, and the allocation of samples was done by a simple randomization method using closed envelopes.
The sample size was calculated using the G*Power Software version. The significance level was fixed at 0.05. The power of the study was fixed at 20% (0.8). The effect size was fixed at 1.21 (calculated based on the results of the previous study). The calculated sample size was 12 per group. The total sample size was 24.
- Children between 8 and 13 years of age
- Children with mild intellectual disability with IQ level between 50 and 69.
- Children with moderate-to-severe intellectual disability
- Children with any other concomitant syndromes.
A general examination of children was done before the study, to assess if he/she comes under the selection criteria. A developmental screening test (DST) was conducted for determining the IQ level of the children with intellectual disabilities.
The test provided a brief and fairly dependable assessment without requiring the use of performance tests. It consisted of a simple chart with items on it which are arranged age wise from 3 months to 15 years. The examiner will start the test by checking the items which are closest to the chronological age of the child to determine the 'basal age' after which the evaluator gradually moves to upper age levels. Each item could be evaluated either by observing the child (e.g., the head is steady, walks) or by asking the parents (comb hair by self) or by asking the child (repeat 3 digits). In each group, the child should succeed in at least 60% of the items. This will determine the mental age of the child.
The IQ of the child was calculated using the formula:
Twenty-four children with IQ levels of 58–67 were included in the study and divided into two groups by picking up envelopes as to which environment the child will be exposed [Figure 1].
The control group comprised 12 children who were exposed to a regular dental environment where oral prophylaxis procedure was carried out in a standard manner.
The experimental group comprised 12 children undergoing treatment in the SADE, wherein the following specific modifications were done in the dental room.
Regular dental overhead lamp was turned off, and slow-moving visual color effects were displayed on the ceiling in the child's visual field.
Camouflaging the instruments
The handles of the instruments were covered with toys [Figures 2345].
The head-mounted lamp was used to direct light into the child's mouth.
Rhythmic music was played through portable speakers.
This stimulus consisted of a wrap designed to look like a butterfly which was wrapped around the child to produce a calming effect. Moreover, oral prophylaxis was carried out in a standard manner.
The pulse rate was recorded using a pulse oximeter, and blood pressure recordings were measured with a digital sphygmomanometer at the start of the treatment, 5 min after starting the treatment, and after completion of the treatment. Children's level of cooperation during the treatment and after completion of each treatment was recorded using the anxiety and cooperation scale given by Veerkamp et al. (modified Venham's clinical ratings for anxiety and cooperative behavior). This standardized scale includes a score range of 0–5 according to the child's behavior.
All data were tabulated and subjected to statistical analysis using software SPSS (IBM version 22.0). The results were analyzed using independent t-test and repeated measured ANOVA for objective assessment of intergroup and intragroup anxiety levels, respectively, and using the Mann–Whitney U-test and Friedman's test for subjective assessment of intergroup and intragroup anxiety levels, respectively, and P < 0.05 was considered statistically significant.
The intergroup comparison showed that there was a statistically significant decrease in the pulse rate at 5 min (P = 0.012) and at the end of the procedure (P = 0.004) and systolic blood at the end of the procedure (P = 0.004) in the SADE and no significant results were noted in the diastolic blood pressure at any time interval (P > 0.05) between the study and control groups [Table 1]. There was a statistically significant decrease in Venham's anxiety rating scale at 5 min and at the end of the SADE (P = 0.000) [Table 2].
The intragroup comparison showed a significant decrease in pulse rate (P = 0.006), systolic blood pressure (P = 0.000), and diastolic blood pressure (P = 0.001) from baseline to the end of the procedure in the SADE and a significant decrease in only systolic blood pressure from baseline to the end in the control group (P = 0.001) [Table 3]. The intragroup comparison showed a significant decrease in Venham's anxiety rating scale from baseline to the end of the procedure in the SADE (P = 0.000) [Table 4].
Deficits in both intellectual and adaptive functioning are hallmarks of intellectual disability. Intellectual disability has an overall impact on a person's growth and development in all functional domains. They require varying degrees of educational guidance, assistance in obtaining health care, community participation, and encouragement.
The intellectual disability must be identified during the child's developmental years. It is difficult to infer an individual's intellectual functioning merely based on conversation and observation. Hence, the usage of standardized tools for its assessment is essential. Thus, in this study, DST by Bharat Raj was used, as it is a highly reliable and valid test to assess and evaluate the IQ level of children with intellectual disabilities.
Lack of manual dexterity is the predominant barrier to the oral health care of children with developmental disabilities, and the major challenges faced in catering to their dental needs for them are lack of adequate knowledge, skills, and training acquired by the dentists as reported by Burtner et al. They also exhibit extreme anxiety, making dental intervention aversive. According to Martin et al., 43.2% of this population reported dental fear as a major obstacle in obtaining comprehensive oral health care.
SADE is a distinct therapy method that is gaining popularity among the various nonpharmacological techniques. This multisensory-stimulating environment is generally presented in a relaxing and pleasurable space known as the “Snoezelen room,” which is a well-illuminated room comprising slow-moving light, calm sound, along with precise tactile sensation. These particular multisensory stimuli served various purposes.
First, the room was partially dimmed, curtailing any disturbing visual stimuli. Direct fluorescent lighting has been reported as flashing and extremely distressing to the eyes. Hence, this lighting in the dental chair was switched off and was substituted with soft-colored, slowly repetitive moving lights.
Previous reports have documented the negative effects of noise, showing that higher noise levels may elevate blood pressure, heart, and respiration rates. Therefore, to camouflage the second sensory stimuli, that is the “noise,” soft music was played in the background to distract the children from the regular loud sounds of the dental equipment (e.g., airotor and suction).
The third sensation was deep pressure. The somatic sensation was provided by means of deep pressure via the butterfly wrap in this study. The wings of the butterfly were wrapped around the child from shoulders to ankles, which provided deep “hugging” pressure input designed to produce a calming effect. Previously, researches were done to support the use of weighted vests (an effect similar to the “butterfly”) for reducing maladaptive behaviors and improving attention in special needs children. Butterfly wrap was used as it slips over the dental chair, thereby not requiring the child to be strapped to a board such as that used for the papoose.
Furthermore, the elimination of visual input of scaling instruments was done to conceal the child's sight by camouflaging them with colorful child-friendly toys to reduce anxiety during the procedure.
Dental anxiety was assessed objectively using a pulse oximeter and sphygmomanometer device, as a pulse oximeter is one of the most acceptable methods for measuring the physiological changes continuously. This was supported by research done by Aughey et al., where in the heart rate displayed by the pulse oximeter and electrocardiography monitor was in close approximation.
In accordance with a study conducted by Potter et al., the mean scores of heart rate and systolic and diastolic blood pressure were reduced in SADE compared to the regular dental setup. The present study showed similar findings where the mean value of pulse rate at 5 min after starting the procedure, at the end of the procedure, and systolic blood pressure at the end of the procedure was lower during oral prophylaxis showing statistically significant results with a P value of 0.012, 0.004, and 0.004, respectively. In relation to values of diastolic blood pressure in the present study, there were no statistically significant results found at baseline, 5 min, and at the end of the procedure.
The intragroup comparison in the study group (i.e. SADE) also showed a statistically significant decrease in pulse rate and systolic and diastolic blood pressure from baseline to the end of the procedure when compared to the regular dental environment where the readings increased consistently from baseline to the end of the procedure, indicating increased dental anxiety among these children in the regular dental environment.
Subjective evaluation of anxiety was assessed relying on a descriptive rating scale, where the evaluator observes the child throughout the dental procedure and gives a score apt for the child's behavioral response. This response was assessed using Venham's anxiety rating scale. The results of the intragroup comparison of Venham's anxiety rating scale among the study group showed a statistically significant reduction in dental anxiety. The intergroup comparison showed a statistically significant decrease in anxiety at 5 min and at the end of the procedure in the SADE and a significant increase in anxiety in a regular dental environment.
These findings were similar to the study conducted by Shapiro et al., which reported a shorter duration of anxious behaviors in SADE compared to the control group. The results were also in agreement with a previous study done by Cermak et al., where the children were relaxed and cooperative during the dental procedure in SADE compared to the control group as assessed by Venham's anxiety rating scale.
Our study results were also identical to the results obtained by Shapiro et al., where there were decreased anxious behaviors and increased cooperation levels as evaluated by Venham's rating scale in normal children and also children with developmental disabilities.
This study showed the possible significance of sensory-adapted environment modification in providing a soothing effect among children with developmental disabilities undergoing a dental procedure. The sensory environment is thought to cushion and hence shield the individual from harsh stimuli by lowering the intensity of visual, auditory, and tactile inputs. Furthermore, the altered sensory environment causes the participant's attention to be focused solely on the moving visual and auditory stimuli, as well as the deep pressure, resulting in an “altered state” with the inevitable reduction in awareness of unpleasant stimuli.
In the SADE, several children reacted emphatically to the multisensory equipment. Few of them preferred the multicolor projection on the wall, while others reciprocated in a positive way to the relaxing and calming music played in the background. There were no remarks about the SADE, which indicates that this novel behavior management technique was effective in managing children with mild intellectual disability by reducing their anxiety levels during dental procedures.
The results of this study showed a correlation with the results of a systematic review done by Ismail et al., which emphasized the importance of a multisensory-adapted dental environment in improving oral health behavior among special needs children in terms of physiological changes, behaviors pain, and sensory discomfort.
Further studies with a larger sample size, with a multivisit assessment of dental anxiety, involving various other dental treatment procedures can be undertaken to prove the effectiveness of SADE.
Sensory-adapted dental environment was proven to be a successful, noninvasive, cost-effective alternative to induce relaxation and decrease anxiety and agitated behaviors in intellectually disabled children, making dental care experience less traumatic, thereby reducing the utilization of general anesthesia and sedation. This study suggests that incorporating sensory adaptations has the potential to improve children's cooperation and consequently quality dental care can be provided.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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