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Application of Psychological Behavioural Therapies in Improving Oral Health for Children and Adolescents with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

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Title: Application of Psychological Behavioural Therapies in Improving Oral Health for Children and Adolescents with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis
Language: English
Authors: Phoebe P. Y. Lam (ORCID 0000-0002-2468-2080), Elise Hoi Wan Fok, Megan Yuen Tung Chan (ORCID 0009-0009-6568-2261), Colman Patrick McGrath, Cynthia Kar Yung Yiu (ORCID 0000-0003-4090-6205)
Source: Autism: The International Journal of Research and Practice. 2025 29(11):2662-2676.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 15
Publication Date: 2025
Document Type: Journal Articles
Information Analyses
Descriptors: Dental Health, Intervention, Hygiene, Autism Spectrum Disorders, Behavior Modification, Program Effectiveness, Psychoeducational Methods, Research, Health Behavior
DOI: 10.1177/13623613251372276
ISSN: 1362-3613
1461-7005
Abstract: This systematic review aimed to summarize the current evidence on the effectiveness of various psychological behavioural therapies in improving oral hygiene maintenance habits and oral health among children with autism. Independent screening and study selection, data extraction, risk of bias assessment, and evaluation of the certainty of evidence were conducted. A total of 16 studies were deemed eligible for qualitative synthesis, with 9 included in quantitative analyses. Psychological behavioural therapies including visual pedagogies, social stories, components of PECS (Picture Exchange Communication System) and Applied Behavioural Analysis, as well as the use of smart device applications all demonstrated improvement in oral health parameters following implementation. However, most studies lacked control groups and exhibited a high risk of bias due to the lack of reporting or failure to account for autism spectrum disorder (ASD) severity and associated comorbidities. In addition, studies typically relied on caregivers to carry out reinforcement of therapies, which may explain the significant heterogeneity observed. In summary, the evidence supporting the use of psychoeducational techniques to improve the oral health parameters of autistic children is limited and of very low certainty. Further research utilizing larger-scale studies and more rigorous study designs is necessary to enhance the certainty of evidence in this field.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1487094
Database: ERIC
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  Value: <anid>AN0188761506;f9d01nov.25;2025Oct23.02:29;v2.2.500</anid> <title id="AN0188761506-1">Application of psychological behavioural therapies in improving oral health for children and adolescents with autism spectrum disorder: A systematic review and meta-analysis </title> <p>This systematic review aimed to summarize the current evidence on the effectiveness of various psychological behavioural therapies in improving oral hygiene maintenance habits and oral health among children with autism. Independent screening and study selection, data extraction, risk of bias assessment, and evaluation of the certainty of evidence were conducted. A total of 16 studies were deemed eligible for qualitative synthesis, with 9 included in quantitative analyses. Psychological behavioural therapies including visual pedagogies, social stories, components of PECS (Picture Exchange Communication System) and Applied Behavioural Analysis, as well as the use of smart device applications all demonstrated improvement in oral health parameters following implementation. However, most studies lacked control groups and exhibited a high risk of bias due to the lack of reporting or failure to account for autism spectrum disorder (ASD) severity and associated comorbidities. In addition, studies typically relied on caregivers to carry out reinforcement of therapies, which may explain the significant heterogeneity observed. In summary, the evidence supporting the use of psychoeducational techniques to improve the oral health parameters of autistic children is limited and of very low certainty. Further research utilizing larger-scale studies and more rigorous study designs is necessary to enhance the certainty of evidence in this field. This review looked at existing studies to see how effective different psychological and behavioural therapies are in helping children with autism take better care of their teeth and maintain good oral health. The researchers carefully selected and analysed 16 studies, with 9 of those used for detailed analysis. The therapies examined included visual tools, social stories, parts of the Picture Exchange Communication System (PECS), Applied Behavioural Analysis (ABA), and smartphone apps. Overall, these approaches showed some improvements in oral health. However, many of the studies had weaknesses, such as not having control groups or not fully considering the severity of the autistic conditions or if other medical conditions are present. In short, the current evidence that these therapies help improve oral health in children with autism is limited and not very strong. More high-quality research with larger groups of children is needed to better understand what works best.</p> <p>Keywords: Autism Spectrum Disorder; behaviour modification; oral health; oral hygiene; systematic review</p> <hd id="AN0188761506-2">Introduction</hd> <p>Parents and caretakers often face challenges with home oral care for autistic children ([<reflink idref="bib35" id="ref1">35</reflink>]). The potential hypersensitivity and oral defensiveness commonly observed in autistic individuals may be the main factors contributing to aversive reactions during oral hygiene maintenance ([<reflink idref="bib35" id="ref2">35</reflink>]). Moreover, the sensory challenges and behavioural issues pose even greater obstacles in carrying out restorations and other dental procedures for individuals with autism ([<reflink idref="bib4" id="ref3">4</reflink>]; [<reflink idref="bib22" id="ref4">22</reflink>]). Advanced pharmacological approaches are often necessary to manage these behavioural challenges for more complex dental treatments ([<reflink idref="bib4" id="ref5">4</reflink>]; [<reflink idref="bib22" id="ref6">22</reflink>]), underscoring the importance of implementing preventive homecare measures against dental decay and other oral diseases in the provision of dental care to autistic children and adolescents.</p> <p>Brushing teeth and maintaining proper oral hygiene require a combination of motor skills and dexterity, adaptive skills for self-care, and cognitive abilities for effective plaque removal. Various psychological behavioural therapies have been developed and tailored to enhance diverse skills in autistic children, showing promising outcomes. Therapist- or caregiver-mediated behavioural and developmental therapies have demonstrated positive advancements among in autistic children ([<reflink idref="bib5" id="ref7">5</reflink>]; [<reflink idref="bib13" id="ref8">13</reflink>]; [<reflink idref="bib39" id="ref9">39</reflink>]). Specifically, comprehensive behavioural interventions, joint attention, and symbolic play interventions have shown beneficial effects on language and communication skills in toddlers diagnosed with autism spectrum disorder (ASD) ([<reflink idref="bib5" id="ref10">5</reflink>]; [<reflink idref="bib13" id="ref11">13</reflink>]; [<reflink idref="bib39" id="ref12">39</reflink>]). Social skills groups may enhance social competence and friendship quality in children and young adults with ASD ([<reflink idref="bib28" id="ref13">28</reflink>]). However, the current evidence supporting early intensive psychological behavioural intervention for enhancing various skills in autistic children remains limited, primarily based on small-scale studies ([<reflink idref="bib27" id="ref14">27</reflink>]; [<reflink idref="bib37" id="ref15">37</reflink>]).</p> <p>Psychological behavioural therapies have also shown some benefits when utilized in dentistry ([<reflink idref="bib16" id="ref16">16</reflink>]). This systematic review evaluated the effectiveness of different psychological behavioural interventions in improving the behaviour of autistic children during dental visits. The implementation of these psychological behavioural therapies has been found to help children become accustomed to the dental facilities, thereby facilitating full participation in dental consultations and assessments ([<reflink idref="bib16" id="ref17">16</reflink>]). However, the overall certainty of the evidence remains limited due to small-scale studies and the presence of confounding factors such as autism severity and previous dental experiences.</p> <p>Regarding the efficacies of psychological behavioural interventions in establishing a consistent habit of oral hygiene and health maintenance, there is also a lack of sufficient research on evaluating the benefits of these therapies. This systematic review aimed to provide a summary of the existing literature evaluating the effectiveness of different psychological behavioural therapies with other behavioural management techniques in improving oral health among autistic children.</p> <hd id="AN0188761506-3">Methods</hd> <p>The systematic review was performed and reported in accordance with the guidelines outlined in Cochrane Handbook for Systematic Review of Interventions ([<reflink idref="bib12" id="ref18">12</reflink>]) and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) ([<reflink idref="bib32" id="ref19">32</reflink>]), respectively. The review protocol was registered with PROSPERO (CRD42023392403).</p> <p>The following PICO(S) statement was utilized:</p> <p></p> <ulist> <item> Participants (P): children and adolescents of 18 years old or younger diagnosed with ASD.</item> <p></p> <item> Interventions (I): Psychological behavioural therapies including but not limited to visual pedagogies (VP) such as social stories and PECS (Picture Exchange Communication System), video modelling (VM), Applied Behaviour Analysis, and TEAACH (Treatment and education of Autistic and Communication-Handicapped Children).</item> <p></p> <item> Control (C): Control includes no interventions, basic behavioural management technique or comparison between another psychological behavioural therapies. Studies evaluating psychological behavioural therapies but with no control group were also accepted in this systematic review.</item> <p></p> <item> Outcomes (O): The change in clinical parameters, including plaque scores or gingival inflammation scores.</item> <p></p> <item> Studies (S): Longitudinal interventional studies which measures at least two time points. Randomized controlled trials or non-randomized studies were also accepted. Cross-sectional studies, reviews were excluded.</item> </ulist> <hd id="AN0188761506-4">Search strategies</hd> <p>Five electronic databases (CINHAL, EMBASE, MEDLINE, PsycINFO, and Web of Science) were strategically searched with broad keywords and MeSH terms (Supplemental Appendix 1) from inception to 27 November 2024. Screening the reference lists of the relevant systematic reviews and the grey literature (opengrey.eu) were also carried out during manual searches to reduce omission of eligible articles.</p> <hd id="AN0188761506-5">Selection of studies</hd> <p>Initial screening by titles and abstracts was performed by two independent reviewers (second and third authors) after calibration with the third reviewer (first author). Full reports of all potentially eligible articles were retrieved and assessed by the two reviewers separately. In case of any disagreement, the third reviewer was consulted for the final verdict.</p> <hd id="AN0188761506-6">Data extraction and management</hd> <p>The two reviewers independently extracted relevant data from each included study with a standardized data extraction spreadsheet. The extracted data encompassed information on participants (recruitment site and country, gender distribution, age range, and inclusion/ exclusion criteria), intervention and control groups (types of psychological behavioural therapies, implementation methods, frequencies, and durations), as well as outcomes (oral health parameters, behaviours, cooperativeness, and other outcome measurements).</p> <hd id="AN0188761506-7">Assessment of risk of bias of included studies</hd> <p>Depending on the study design, the Risk of Bias 2 (RoB 2) tool ([<reflink idref="bib36" id="ref20">36</reflink>]), Risk of Bias in Non-Randomized Studies of Interventions Tool (ROBINS-I tool) ([<reflink idref="bib40" id="ref21">40</reflink>]), and the Newcastle-Ottawa Scale (NOS) ([<reflink idref="bib38" id="ref22">38</reflink>]) were utilized to assess the risk of bias in the included studies. The ROBINS-I tool comprises seven domains: (I) bias due to confounding, (II) bias in participant selection, (III) bias in intervention classification, (IV) bias due to deviations from intended interventions, (V) bias due to missing data, (VI) bias in outcome measurement, and (VII) bias in reporting of results. An overall rating of the study (low, moderate, serious, or critical risk) was assigned after evaluating all domains ([<reflink idref="bib40" id="ref23">40</reflink>]). NOS evaluated studies based on three domains: selection, comparability, and outcomes, with a maximum score of 9. NOS was utilized for interventional studies lacking control groups. ([<reflink idref="bib38" id="ref24">38</reflink>]). Risk of bias assessments were conducted by two independent reviewers.</p> <hd id="AN0188761506-8">Measures of effect</hd> <p>In meta-analyses, continuous outcomes were compared with weighted or standardized mean difference when appropriate, and together with 95% confidence intervals ([<reflink idref="bib12" id="ref25">12</reflink>]). Dichotomous outcomes were evaluated with odds ratio with 95% confidence intervals if applicable ([<reflink idref="bib12" id="ref26">12</reflink>]). Narrative reporting of the results was performed if meta-analysis could not be carried out due to missing data in reporting.</p> <hd id="AN0188761506-9">Data synthesis and subgroup analyses</hd> <p>Meta-analyses were conducted following the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions ([<reflink idref="bib12" id="ref27">12</reflink>]) using Stata version 13.1. A fixed-effect model was utilized when fewer than five studies were included in the meta-analysis; otherwise, a random-effect model was chosen for the analyses ([<reflink idref="bib12" id="ref28">12</reflink>]). Subgroup analyses were conducted in the presence of different evaluation time points, potential confounding factors, when comparing different control interventions, or if there were notable differences ([<reflink idref="bib12" id="ref29">12</reflink>]). Sensitivity analysis was carried out to identify any significant deviations in results among the included studies when appropriate ([<reflink idref="bib12" id="ref30">12</reflink>]). Results were presented descriptively only if the included studies exhibited significant dissimilarities ([<reflink idref="bib12" id="ref31">12</reflink>]).</p> <hd id="AN0188761506-10">Assessment of heterogeneity and publication bias</hd> <p>Inconsistency between studies was assessed with both <emph>I</emph><sups>2</sups> statistics and chi-square tests. If either <emph>I</emph><sups>2</sups> statistics exceeded 60% or the <emph>p</emph>-value of the chi-square test was below 0.05, the heterogeneity between studies in meta-analysis was deemed significant ([<reflink idref="bib12" id="ref32">12</reflink>]).</p> <p>Publication bias was only assessed with funnel plots if there were more than 10 studies included in a meta-analysis ([<reflink idref="bib12" id="ref33">12</reflink>]).</p> <hd id="AN0188761506-11">Assessment of quality of evidence</hd> <p>The certainty of evidence for all outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Initially, the certainty of evidence started as high for randomized controlled trials and low for non-randomized studies. Subsequently, they were further evaluated based on any concerns arising from the risk of bias in the included studies, inconsistency, indirectness, and publication bias. If any outcomes showed a substantial effect size, dose-response relationship, and minimal plausible confounding factors, the certainty of evidence was upgraded ([<reflink idref="bib30" id="ref34">30</reflink>]).</p> <hd id="AN0188761506-12">Results</hd> <p>Preliminary systematic search yielded 1249 records after removal of duplicates. After independent screening through titles and abstracts, 53 articles were retrieved for full-text reviews (κ = 0.893). A total of 16 studies evaluated the use of psychological behavioural therapies on the improvement of toothbrushing ([<reflink idref="bib1" id="ref35">1</reflink>]; [<reflink idref="bib3" id="ref36">3</reflink>]; [<reflink idref="bib6" id="ref37">6</reflink>]; [<reflink idref="bib9" id="ref38">9</reflink>]; [<reflink idref="bib10" id="ref39">10</reflink>]; [<reflink idref="bib14" id="ref40">14</reflink>]; [<reflink idref="bib19" id="ref41">19</reflink>]; [<reflink idref="bib21" id="ref42">21</reflink>]; [<reflink idref="bib23" id="ref43">23</reflink>]; [<reflink idref="bib24" id="ref44">24</reflink>]; [<reflink idref="bib25" id="ref45">25</reflink>]; [<reflink idref="bib26" id="ref46">26</reflink>]; [<reflink idref="bib29" id="ref47">29</reflink>]; [<reflink idref="bib31" id="ref48">31</reflink>]; [<reflink idref="bib34" id="ref49">34</reflink>]; [<reflink idref="bib42" id="ref50">42</reflink>]). Psychological techniques including VP, VM, social stories, PECS, Mobile, and iPad applications were being investigated by the included studies. All behavioural interventions were reported to be effective in improving oral health parameters among autistic kids. The PRISMA flowchart and a list of the 37 excluded studies with their respective reasons are detailed in Figure 1 and Supplemental Appendix 2, respectively.</p> <p>Graph: Figure 1. PRISMA flow diagram.</p> <hd id="AN0188761506-13">Study characteristics</hd> <p>The included studies were mainly conducted in Asian countries ([<reflink idref="bib1" id="ref51">1</reflink>]; [<reflink idref="bib6" id="ref52">6</reflink>]; [<reflink idref="bib10" id="ref53">10</reflink>]; [<reflink idref="bib14" id="ref54">14</reflink>]; [<reflink idref="bib21" id="ref55">21</reflink>]; [<reflink idref="bib24" id="ref56">24</reflink>]; [<reflink idref="bib26" id="ref57">26</reflink>]; [<reflink idref="bib29" id="ref58">29</reflink>]; [<reflink idref="bib34" id="ref59">34</reflink>]; [<reflink idref="bib42" id="ref60">42</reflink>]), while the remaining were conducted in European countries ([<reflink idref="bib3" id="ref61">3</reflink>]; [<reflink idref="bib19" id="ref62">19</reflink>]; [<reflink idref="bib23" id="ref63">23</reflink>]), the United States ([<reflink idref="bib9" id="ref64">9</reflink>]; [<reflink idref="bib25" id="ref65">25</reflink>]), and Egypt ([<reflink idref="bib31" id="ref66">31</reflink>]). Only one study was published in the 2000s ([<reflink idref="bib23" id="ref67">23</reflink>]), three studies were published in the 2010s ([<reflink idref="bib19" id="ref68">19</reflink>]; [<reflink idref="bib25" id="ref69">25</reflink>]; [<reflink idref="bib26" id="ref70">26</reflink>]), and the remaining studies were published in the 2020s ([<reflink idref="bib1" id="ref71">1</reflink>]; [<reflink idref="bib3" id="ref72">3</reflink>]; [<reflink idref="bib6" id="ref73">6</reflink>]; [<reflink idref="bib9" id="ref74">9</reflink>]; [<reflink idref="bib10" id="ref75">10</reflink>]; [<reflink idref="bib14" id="ref76">14</reflink>]; [<reflink idref="bib21" id="ref77">21</reflink>]; [<reflink idref="bib24" id="ref78">24</reflink>]; [<reflink idref="bib29" id="ref79">29</reflink>]; [<reflink idref="bib31" id="ref80">31</reflink>]; [<reflink idref="bib34" id="ref81">34</reflink>]; [<reflink idref="bib42" id="ref82">42</reflink>]). Out of the 16 studies included, seven were interventional studies without a control group ([<reflink idref="bib3" id="ref83">3</reflink>]; [<reflink idref="bib6" id="ref84">6</reflink>]; [<reflink idref="bib19" id="ref85">19</reflink>]; [<reflink idref="bib23" id="ref86">23</reflink>]; [<reflink idref="bib29" id="ref87">29</reflink>]; [<reflink idref="bib34" id="ref88">34</reflink>]; [<reflink idref="bib42" id="ref89">42</reflink>]), three were non-randomized or quasi-randomized clinical trials ([<reflink idref="bib14" id="ref90">14</reflink>]; [<reflink idref="bib24" id="ref91">24</reflink>]; [<reflink idref="bib26" id="ref92">26</reflink>]), and six were randomized controlled trials with either positive or negative control groups ([<reflink idref="bib1" id="ref93">1</reflink>]; [<reflink idref="bib9" id="ref94">9</reflink>]; [<reflink idref="bib10" id="ref95">10</reflink>]; [<reflink idref="bib21" id="ref96">21</reflink>]; [<reflink idref="bib25" id="ref97">25</reflink>]; [<reflink idref="bib31" id="ref98">31</reflink>]). Subjects were recruited from similar settings, such as special needs schools or centres ([<reflink idref="bib6" id="ref99">6</reflink>]; [<reflink idref="bib14" id="ref100">14</reflink>]; [<reflink idref="bib15" id="ref101">15</reflink>]; [<reflink idref="bib19" id="ref102">19</reflink>]; [<reflink idref="bib21" id="ref103">21</reflink>]; [<reflink idref="bib24" id="ref104">24</reflink>]; [<reflink idref="bib26" id="ref105">26</reflink>]; [<reflink idref="bib29" id="ref106">29</reflink>]; [<reflink idref="bib42" id="ref107">42</reflink>]), psychiatric wards or diagnostic clinics ([<reflink idref="bib1" id="ref108">1</reflink>]; [<reflink idref="bib3" id="ref109">3</reflink>]; [<reflink idref="bib31" id="ref110">31</reflink>]), or special needs dental clinics ([<reflink idref="bib9" id="ref111">9</reflink>]; [<reflink idref="bib10" id="ref112">10</reflink>]; [<reflink idref="bib23" id="ref113">23</reflink>]; [<reflink idref="bib25" id="ref114">25</reflink>]; [<reflink idref="bib34" id="ref115">34</reflink>]).</p> <hd id="AN0188761506-14">Risk of bias assessment</hd> <p>Among the six randomized controlled trials ([<reflink idref="bib1" id="ref116">1</reflink>]; [<reflink idref="bib9" id="ref117">9</reflink>]; [<reflink idref="bib10" id="ref118">10</reflink>]; [<reflink idref="bib21" id="ref119">21</reflink>]; [<reflink idref="bib25" id="ref120">25</reflink>]; [<reflink idref="bib31" id="ref121">31</reflink>]), all studies raised some concerns regarding the risk of bias due to deviations from the intended interventions, as they relied on caregivers to varying degrees to administer the intervention or control therapy. Since blinding of the caregivers was not feasible, potential deviations such as inconsistent implementation or varying frequencies could have occurred without detailed information, impacting the outcomes. Three studies did not conduct multiple eligible analyses for the data, which raised some concerns for the risk of bias in selection of reported results ([<reflink idref="bib10" id="ref122">10</reflink>]; [<reflink idref="bib21" id="ref123">21</reflink>]; [<reflink idref="bib25" id="ref124">25</reflink>]). Consequently, four studies were deemed to have some concerns regarding the overall risk of bias ([<reflink idref="bib1" id="ref125">1</reflink>]; [<reflink idref="bib10" id="ref126">10</reflink>]; [<reflink idref="bib21" id="ref127">21</reflink>]; [<reflink idref="bib25" id="ref128">25</reflink>]) when assessed with ROB 2 ([<reflink idref="bib36" id="ref129">36</reflink>]), while two additional studies were classified as high risk since blinding of outcome assessors were not mentioned in the study ([<reflink idref="bib9" id="ref130">9</reflink>]; [<reflink idref="bib31" id="ref131">31</reflink>]) (Figure 2(a)).</p> <p>Graph: Figure 2. (a) ROB diagram; (b) ROBINS-I diagram; and (c) NOS diagram.</p> <p>Applying the ROBINS-I tool, the three non-randomized trials ([<reflink idref="bib14" id="ref132">14</reflink>]; [<reflink idref="bib24" id="ref133">24</reflink>]; [<reflink idref="bib26" id="ref134">26</reflink>]) did not control for significant confounding factors, such as the severity of ASD and associated comorbidities, including intellectual abilities and/or cognitive functioning. As a result, these trials exhibited a serious risk of bias in the domain of bias due to confounding (Domain I) and overall risk of bias (Figure 2(b)).</p> <p>The NOS scores for the seven interventional studies ([<reflink idref="bib3" id="ref135">3</reflink>]; [<reflink idref="bib6" id="ref136">6</reflink>]; [<reflink idref="bib19" id="ref137">19</reflink>]; [<reflink idref="bib23" id="ref138">23</reflink>]; [<reflink idref="bib29" id="ref139">29</reflink>]; [<reflink idref="bib34" id="ref140">34</reflink>]; [<reflink idref="bib42" id="ref141">42</reflink>]) range from 4/9 to full marks. Among them, three studies scored above 7/9 ([<reflink idref="bib6" id="ref142">6</reflink>]; [<reflink idref="bib34" id="ref143">34</reflink>]; [<reflink idref="bib42" id="ref144">42</reflink>]), indicating high quality. Three studies were of moderate quality ([<reflink idref="bib3" id="ref145">3</reflink>]; [<reflink idref="bib19" id="ref146">19</reflink>]; [<reflink idref="bib29" id="ref147">29</reflink>]), scoring between 5 and 6/9, while one study scored 4/9 ([<reflink idref="bib23" id="ref148">23</reflink>]). The main reasons for the moderate and low scores included inadequate justification of sample size, lack of appropriate statistical analysis of potential confounders, and subgroup analyses (Figure 2(c)).</p> <hd id="AN0188761506-15">Visual Pedagogy (VP)</hd> <p>Twelve longitudinal studies assessed whether the implementation of different formats of VP lead to changes in oral hygiene maintenance among autistic children ([<reflink idref="bib1" id="ref149">1</reflink>]; [<reflink idref="bib6" id="ref150">6</reflink>]; [<reflink idref="bib9" id="ref151">9</reflink>]; [<reflink idref="bib10" id="ref152">10</reflink>]; [<reflink idref="bib14" id="ref153">14</reflink>]; [<reflink idref="bib21" id="ref154">21</reflink>]; [<reflink idref="bib23" id="ref155">23</reflink>]; [<reflink idref="bib24" id="ref156">24</reflink>]; [<reflink idref="bib29" id="ref157">29</reflink>]; [<reflink idref="bib31" id="ref158">31</reflink>]; [<reflink idref="bib34" id="ref159">34</reflink>]; [<reflink idref="bib42" id="ref160">42</reflink>]). Among these studies, four were interventional studies without a control group ([<reflink idref="bib6" id="ref161">6</reflink>]; [<reflink idref="bib23" id="ref162">23</reflink>]; [<reflink idref="bib34" id="ref163">34</reflink>]; [<reflink idref="bib42" id="ref164">42</reflink>]), one compared typical VP with culturally adapted VP ([<reflink idref="bib1" id="ref165">1</reflink>]), and the rest compared VP with VM ([<reflink idref="bib9" id="ref166">9</reflink>]; [<reflink idref="bib10" id="ref167">10</reflink>]; [<reflink idref="bib24" id="ref168">24</reflink>]; [<reflink idref="bib31" id="ref169">31</reflink>]), a mobile app ([<reflink idref="bib14" id="ref170">14</reflink>]), conventional oral hygiene instructions (OHI) ([<reflink idref="bib21" id="ref171">21</reflink>]). The VP included social story ([<reflink idref="bib6" id="ref172">6</reflink>]; [<reflink idref="bib23" id="ref173">23</reflink>]; [<reflink idref="bib34" id="ref174">34</reflink>]; [<reflink idref="bib42" id="ref175">42</reflink>]), Picture Exchange Communication System (PECS) ([<reflink idref="bib29" id="ref176">29</reflink>]; [<reflink idref="bib31" id="ref177">31</reflink>]), edited photos or pictures ([<reflink idref="bib9" id="ref178">9</reflink>]; [<reflink idref="bib10" id="ref179">10</reflink>]; [<reflink idref="bib24" id="ref180">24</reflink>]; [<reflink idref="bib31" id="ref181">31</reflink>]) and drawing ([<reflink idref="bib1" id="ref182">1</reflink>]; [<reflink idref="bib34" id="ref183">34</reflink>]). The formats of VP used included booklets, pamphlets, laminated photos, or posters. In all studies parents or caregivers were responsible for displaying the materials in a visible location during toothbrushing or as desired ([<reflink idref="bib9" id="ref184">9</reflink>]; [<reflink idref="bib10" id="ref185">10</reflink>]; [<reflink idref="bib23" id="ref186">23</reflink>]; [<reflink idref="bib24" id="ref187">24</reflink>]; [<reflink idref="bib29" id="ref188">29</reflink>]); however, most of the research team initially delivered the VP to the participants ([<reflink idref="bib21" id="ref189">21</reflink>]; [<reflink idref="bib31" id="ref190">31</reflink>]; [<reflink idref="bib34" id="ref191">34</reflink>]; [<reflink idref="bib42" id="ref192">42</reflink>]). All twelve studies reported a significant improvement in oral hygiene among children with ASD following the introduction of VP, as measured by various outcomes ([<reflink idref="bib1" id="ref193">1</reflink>]; [<reflink idref="bib6" id="ref194">6</reflink>]; [<reflink idref="bib9" id="ref195">9</reflink>]; [<reflink idref="bib10" id="ref196">10</reflink>]; [<reflink idref="bib14" id="ref197">14</reflink>]; [<reflink idref="bib21" id="ref198">21</reflink>]; [<reflink idref="bib23" id="ref199">23</reflink>]; [<reflink idref="bib24" id="ref200">24</reflink>]; [<reflink idref="bib29" id="ref201">29</reflink>]; [<reflink idref="bib31" id="ref202">31</reflink>]; [<reflink idref="bib34" id="ref203">34</reflink>]; [<reflink idref="bib42" id="ref204">42</reflink>]).</p> <p>Nine studies compared the pre- and post-intervention plaque scores (PI) or simplified oral hygiene index (OHI-S) ([<reflink idref="bib1" id="ref205">1</reflink>]; [<reflink idref="bib6" id="ref206">6</reflink>]; [<reflink idref="bib9" id="ref207">9</reflink>]; [<reflink idref="bib14" id="ref208">14</reflink>]; [<reflink idref="bib21" id="ref209">21</reflink>]; [<reflink idref="bib24" id="ref210">24</reflink>]; [<reflink idref="bib29" id="ref211">29</reflink>]; [<reflink idref="bib31" id="ref212">31</reflink>]; [<reflink idref="bib34" id="ref213">34</reflink>]). Based on the weighted mean difference in the meta-analyses with fixed-effect models, a statistically significant mean plaque reduction was found at 1 month (PI: −0.73; 95% CI, −1.03, −0.43; 95% CI; <emph>p</emph> < 0.001), 3 months (PI: −1.19; 95% CI, −1.22, −1.15; 95% CI; <emph>p</emph> < 0.001; OHI-S: −0.62; 95% CI, −0.70, −0.55; <emph>p</emph> < 0.001), and 6 months (PI: −0.43; 95% CI, −0.49, −0.37; 95% CI, <emph>p</emph> < 0.001). However, the heterogeneity was significant in all analyses (1 month PI: <emph>I</emph><sups>2</sups>, 98.3%, <emph>p</emph> < 0.001; 3 months PI: <emph>I</emph><sups>2</sups>, 99.7%, <emph>p</emph> < 0.001; 3 months OHI-S: <emph>I</emph><sups>2</sups>, 99.0%, <emph>p</emph> < 0.001; 6 months PI: <emph>I</emph><sups>2</sups>, 95.9%, <emph>p</emph> < 0.001). Sensitivity analysis was not conducted due to the limited number of studies included in each subgroup analysis and the significant heterogeneity identified. The certainty of evidence was deemed low due to significant heterogeneity and imprecision with respect to small-scaled study (Figure 3(a) and (b)).</p> <p>Graph: Figure 3. (a) Meta-analysis. Change in plaque after visual pedagogy interventions (Plaque index); (b) Meta-analysis. Change in plaque after visual pedagogy interventions (Simplified Oral Hygiene Index).</p> <p>Five studies utilized gingival index (GI) to assess the effectiveness of VP ([<reflink idref="bib6" id="ref214">6</reflink>]; [<reflink idref="bib9" id="ref215">9</reflink>]; [<reflink idref="bib14" id="ref216">14</reflink>]; [<reflink idref="bib21" id="ref217">21</reflink>]; [<reflink idref="bib42" id="ref218">42</reflink>]). The review period ranged from 1 to 6 months, all studies consistently reported a reduction in mean GI scores. The reduction of mean GI scores at 1, 3 and 6 months were −0.43 (95% CI, −0.47, −0.39; <emph>p</emph> < 0.001), −0.61 (95% CI, −0.65, −0.58; <emph>p</emph> < 0.001) and −0.36 (95% CI, −0.41, −0.31; <emph>p</emph> < 0.001), respectively. The heterogeneity was found to be significant at 3 months (<emph>I</emph><sups>2</sups>, 99.8%, <emph>p</emph> < 0.001) and 6 months (<emph>I</emph><sups>2</sups>, 94.2%, <emph>p</emph> < 0.001); but not at 1 month (<emph>I</emph><sups>2</sups>, 0.0%, <emph>p</emph> = 0.348), undermining the certainty of results (Figure 4). Due to the notable heterogeneity observed as well as the small number of studies included, sensitivity analysis was not performed Table 1.</p> <p>Graph: Figure 4. Meta-analysis. Change in gingival inflammation after visual pedagogy interventions (Gingival Index).</p> <p>Table 1. Characteristics of studies.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">No</th><th align="left">Study (Year & Country)<xref ref-type="table-fn" rid="tfn1">a</xref></th><th align="left">ASD diagnosis</th><th align="left">Recruitment</th><th align="left">Intervention & control group</th><th align="left">N Patient(% M);Age range (years old)</th><th align="left">Follow-up time</th><th align="left">Outcome assessment</th><th align="left">Confounders</th></tr></thead><tbody><tr><td rowspan="2">1</td><td rowspan="2"><xref ref-type="bibr" rid="bibr1">Aljubour et al. (2022)</xref> SAU, RCT</td><td rowspan="2"><italic>DSM-5</italic> (2013) all levels of ASD severity</td><td rowspan="2">ASD diagnosis clinic</td><td>Cultural-adapted visual pedagogy (drawings)</td><td>32 (66); 6–12</td><td rowspan="2">4 weeks</td><td rowspan="2">Plaque index score</td><td rowspan="2">ToothbrushingBrushing frequencyCaregivers' assistanceASD severityGender</td></tr><tr><td>Regular visual pedagogy (drawings)</td><td>32 (68); 6–12</td></tr><tr><td>2</td><td><xref ref-type="bibr" rid="bibr3">Carli et al. (2022)</xref> ITA, ISWC</td><td><italic>DSM-5</italic> (2013) all levels of ASD severity</td><td>Local child psychiatry unit</td><td>Application software</td><td>100 (78); 7–16</td><td>1 week1 month3 months</td><td>Plaque index scoresGingival indexdmft/DMFTFrequency of toothbrushingFrequency of snacking</td><td>NR</td></tr><tr><td>3</td><td><xref ref-type="bibr" rid="bibr6">Du et al. (2021)</xref> HKG, ISWC</td><td><italic>DSM-5</italic> (2013) all levels of ASD severity</td><td>Special childcare centres</td><td>Visual pedagogy</td><td>122 (84); 3–6</td><td>3 months6 months</td><td>% with plaquePlaque index scores% with gingivitisGingival index scores</td><td>AgeGenderParental educationFamily incomeCognitive functioningSocial skillsCommunication skillsReading skillsChallenging behaviours</td></tr><tr><td rowspan="2">4</td><td rowspan="2"><xref ref-type="bibr" rid="bibr8">Fenning et al. (2022)</xref>ITA, RCT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">Hospital-affiliated sites</td><td>Parent training</td><td>60 (82); 3–13</td><td rowspan="2">3 months6 months</td><td rowspan="2">Change in toothbrushing frequencyPlaque levelChild behavioural problemsDental Caries development</td><td rowspan="2">GenderRace and ethnicityIQAdaptive behaviourASD symptom severityBehaviour problemPrimary caregiver sociodemographic factorsFamily incomeBaseline home oral hygieneBaseline oral health</td></tr><tr><td>Psychoeducational dental toolkit</td><td>60 (88); 3–13</td></tr><tr><td rowspan="2">5</td><td rowspan="2"><xref ref-type="bibr" rid="bibr9">Gandhi et al. (2024)</xref>USA, RCT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">Children hospital dental centre</td><td>Video modelling (young girl model)</td><td>20 (95), 4–12</td><td rowspan="2">30 days</td><td rowspan="2">Plaque scoresGingival scores</td><td rowspan="2">GenderAge</td></tr><tr><td>Toothbrushing social story</td><td>20 (85), 4–12</td></tr><tr><td rowspan="2">6</td><td rowspan="2"><xref ref-type="bibr" rid="bibr10">Gharavi et al. (2024)</xref>IRN, RCT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">Special needs teaching clinic</td><td>Video modelling</td><td rowspan="2">32 (75), 10–12</td><td rowspan="2">1 month3 months</td><td rowspan="2">Toothbrushing stage</td><td rowspan="2">NR</td></tr><tr><td>Visual pedagogy (poster)</td></tr><tr><td rowspan="2">7</td><td rowspan="2"><xref ref-type="bibr" rid="bibr14">Krishnan et al. (2021)</xref> IND,NRT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">Special schools</td><td>Visual pedagogy (cards)</td><td>30 (67), 13–17</td><td rowspan="2">1.5 months3 months</td><td rowspan="2">Plaque index scoresGingival index scores</td><td rowspan="2">AgeGenderSociodemographic factors</td></tr><tr><td>Video modelling (mobile based application)</td><td>30 (90), 13–17</td></tr><tr><td>8</td><td><xref ref-type="bibr" rid="bibr19">Lopez Cazaux et al. (2019)</xref> FRA, ISWC</td><td><italic>DSM-5</italic> (2013)</td><td>Schools and care centres</td><td>Video modelling (iPad)</td><td>52 (87); 3–19</td><td>4 months8 months</td><td>Toothbrushing steps</td><td>NR</td></tr><tr><td rowspan="2">9</td><td rowspan="2"><xref ref-type="bibr" rid="bibr21">Pai Khot et al. (2023)</xref>SAU; RCT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">Special schools</td><td>Visual pedagogy (Picture assisted illustration reinforcement (PAIR) system)</td><td rowspan="2">60 (63); 7–18</td><td rowspan="2">3 months</td><td rowspan="2">Oral hygiene index simplifiedGingival scores</td><td rowspan="2">Autism spectrum quotientVineland society maturity scaleIQFrankl behavioural scaleOral health conditions</td></tr><tr><td>Conventional verbal technique for oral health education</td></tr><tr><td>10</td><td><xref ref-type="bibr" rid="bibr23">Pilebro and Backman (2005)</xref> SWE, ISWC</td><td><italic>DSM-IV</italic> (1994)</td><td>Dental school</td><td>Visual pedagogy (picture)</td><td>14 (100); 5–13</td><td>8 months12 months18 months</td><td>Toothbrushing stepsAmount of plaqueParents' opinions</td><td>AgeLevel of communicationCaries experiencePrevious treatment under general anaesthesia</td></tr><tr><td rowspan="2">11</td><td rowspan="2"><xref ref-type="bibr" rid="bibr24">Piraneh et al. (2023)</xref> IRN, QRCT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">4 Primary schools</td><td>Visual pedagogy (social story)</td><td>79 (100); 7–15</td><td rowspan="2">1 month</td><td rowspan="2">OHI-S improvement</td><td rowspan="2">AgeParents' oral health knowledge and attitudeParents' education levelFamily incomeLevel of ASDCooperation levelsOral health habits</td></tr><tr><td>Video modelling</td><td>58 (100); 7–15</td></tr><tr><td rowspan="2">12</td><td rowspan="2"><xref ref-type="bibr" rid="bibr26">Ramassamy et al. (2019)</xref>IND, NRIT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">2 special schools</td><td>Visual pedagogy and video modelling and yoga</td><td>36 (81); 7–15</td><td rowspan="2">1 month2 months3 months6 months</td><td rowspan="2">Plaque index scoreGingival index score</td><td rowspan="2">AgeGender</td></tr><tr><td>Visual pedagogy and video modelling</td><td>36 (83); 7–15</td></tr><tr><td rowspan="2">13</td><td rowspan="2"><xref ref-type="bibr" rid="bibr31">Shalabi et al (2022)</xref>EGY, RCT</td><td rowspan="2"><italic>DSM-5</italic> (2013)</td><td rowspan="2">Autistic therapeutic centres</td><td>Visual pedagogy (Picture Examination Communication System)</td><td>25 (68); NR</td><td rowspan="2">3 months6 months12 months</td><td rowspan="2">OHI-s scores</td><td rowspan="2">AgeGenderASD severity</td></tr><tr><td>Video modelling</td><td>25 (72); NR</td></tr><tr><td>14</td><td><xref ref-type="bibr" rid="bibr34">Smutkeeree et al. (2020)</xref> THA, ISWC</td><td><italic>DSM-5</italic> (2013)</td><td>Child and adolescent mental health institute</td><td>Visual pedagogy</td><td>30 (83) 5–17</td><td>4 weeks3 months6 months</td><td>Plaque index score</td><td>AgeGenderEducation programmeDental care experiencePrevious use of visual pedagogyASD severity</td></tr><tr><td>15</td><td><xref ref-type="bibr" rid="bibr42">Zhou et al. (2020)</xref> HKG, ISWC</td><td><italic>DSM-5</italic> (2013)</td><td>Special childcare centres</td><td>Visual pedagogy (Social story)</td><td>87 (NR), 3–6</td><td>6 months</td><td>Toothbrushing stepsToothbrushing durationSimplified Debris IndexModified Gingival Index</td><td>Intellectual impairmentParents attitudesGender</td></tr></tbody></table> </ephtml> </p> <p>1 ISO alpha-3 codes of countries.</p> <p>2 ABA = Applied Behaviour Analysis; ASD = autism spectrum disorder; IQ = Intelligence quotient; ISWC = interventional study without control; NRIT = non-randomized interventional trial; NR = not reported; PECS = Picture Exchange Communication System; RCT = randomized controlled trial.</p> <hd id="AN0188761506-16">Video Modelling and Visual Pedagogy</hd> <p>Four studies, including four randomized controlled trials ([<reflink idref="bib9" id="ref219">9</reflink>]; [<reflink idref="bib10" id="ref220">10</reflink>]; [<reflink idref="bib25" id="ref221">25</reflink>]; [<reflink idref="bib31" id="ref222">31</reflink>]) and one quasi-randomized trial ([<reflink idref="bib24" id="ref223">24</reflink>]), compared the effectiveness of VM versus VP in improving oral hygiene.</p> <p>The modelling videos utilized in these five studies exhibit significant diversity ([<reflink idref="bib9" id="ref224">9</reflink>]; [<reflink idref="bib10" id="ref225">10</reflink>]; [<reflink idref="bib24" id="ref226">24</reflink>]; [<reflink idref="bib25" id="ref227">25</reflink>]; [<reflink idref="bib31" id="ref228">31</reflink>]). One study employed an animated video ([<reflink idref="bib31" id="ref229">31</reflink>]), while the other four utilized real individuals to demonstrate proper toothbrushing techniques ([<reflink idref="bib9" id="ref230">9</reflink>]; [<reflink idref="bib10" id="ref231">10</reflink>]; [<reflink idref="bib24" id="ref232">24</reflink>]; [<reflink idref="bib25" id="ref233">25</reflink>]), with three featuring older children ([<reflink idref="bib9" id="ref234">9</reflink>]; [<reflink idref="bib24" id="ref235">24</reflink>]; [<reflink idref="bib25" id="ref236">25</reflink>]) and one not specifying the actor or actress details. The video lengths ranged from 58 s to 3 min. One study used a muted video ([<reflink idref="bib10" id="ref237">10</reflink>]), while the others included an audio guide ([<reflink idref="bib9" id="ref238">9</reflink>]; [<reflink idref="bib24" id="ref239">24</reflink>]; [<reflink idref="bib25" id="ref240">25</reflink>]; [<reflink idref="bib31" id="ref241">31</reflink>]). Two studies indicated the presence of 20–23 steps in the demonstration ([<reflink idref="bib9" id="ref242">9</reflink>]; [<reflink idref="bib24" id="ref243">24</reflink>]), while the remaining studies did not specify the number of steps included. In addition, two studies reported that the Fones' toothbrushing method was taught ([<reflink idref="bib24" id="ref244">24</reflink>]; [<reflink idref="bib31" id="ref245">31</reflink>]). Similar to the VP described above, the studies depended on parents or caregivers to provide ongoing reinforcement by incorporating the videos into the daily routine.</p> <p>Among the four studies that evaluated plaque levels, two found that VM led to a more significant reduction in plaque scores than VP ([<reflink idref="bib24" id="ref246">24</reflink>]; [<reflink idref="bib31" id="ref247">31</reflink>]), while two studies reported no difference between the two interventions ([<reflink idref="bib9" id="ref248">9</reflink>]; [<reflink idref="bib25" id="ref249">25</reflink>]). However, due to variations in review durations, reporting and measurement methods, meta-analyses could not be conducted. Furthermore, the two randomized controlled trials included ([<reflink idref="bib10" id="ref250">10</reflink>]; [<reflink idref="bib31" id="ref251">31</reflink>]) were found to have a high risk of bias, while the remaining non-randomized clinical trial was assessed to have some concerns regarding bias ([<reflink idref="bib24" id="ref252">24</reflink>]). Sensitivity analysis was not performed due to the limited number of studies found.</p> <hd id="AN0188761506-17">Other comparisons with VP</hd> <p>[<reflink idref="bib1" id="ref253">1</reflink>] conducted a comparative analysis between culturally adapted VP and standard VP. Both forms of VP, presented as drawings, showed improvements in plaque scores. However, the culturally adapted VP exhibited a significantly greater reduction in plaque scores compared to the standard VP (<emph>p</emph> = 0.003).</p> <p>In the study by [<reflink idref="bib21" id="ref254">21</reflink>], a comparison was made between VP in the form of "Picture Assisted Illustration Reinforcement" derived from applied behaviour analysis, and a conventional OHI reinforcement. The results indicated that the former approach resulted in a significantly greater reduction in plaque scores compared to the conventional OHI (<emph>p</emph> < 0.05).</p> <p>Both studies raised some concerns about risk of bias due to inability to blind the caregivers and recipients of the interventions.</p> <hd id="AN0188761506-18">Toothbrushing training programmes on smart devices</hd> <p>One study evaluated a toothbrushing training programme using visuals in iPad ([<reflink idref="bib3" id="ref255">3</reflink>]). The programme demonstrated success in significantly improving the steps of toothbrushing achieved. However, no control group was included in this study and no other oral health parameters, such as plaque scores or gingival scores were used to further validate its success. The study was deemed to have a moderate risk of bias due to the lack of assessment or reporting of confounding factors such as sociodemographic factors of the participants, severity of ASD, and associated comorbidities.</p> <p>Another study compared the use of a mobile app featuring a video game and dynamic music related to toothbrushing with VP in the form of picture cards ([<reflink idref="bib14" id="ref256">14</reflink>]). Both groups reported significant reductions in plaque and gingival scores, with no statistical difference between the two interventions. Despite controlling for age and gender in both groups, some concerns regarding the risk of bias were still present as the study did not account for ASD severity, associated comorbidities, and lack of randomization.</p> <hd id="AN0188761506-19">Yoga</hd> <p>In a non-randomized study by [<reflink idref="bib26" id="ref257">26</reflink>], the effectiveness of combining yoga with VM and VP was compared to using VM and VP alone to improve toothbrushing efficacy in 72 autistic children aged 7–15 years. The research demonstrated a statistically significant reduction in plaque and gingival inflammation over the 6-month period, as assessed monthly.</p> <hd id="AN0188761506-20">Discussion</hd> <p>This systematic review examined existing literature to identify evidence indicating the potential benefits of various psychological behavioural therapies, including VP, VM, social stories, PECS, Mobile and iPad applications, in enhancing oral health among autistic children. All proposed interventions resulted in a reduction in plaque and gingival inflammation and an improvement in toothbrushing techniques. Separate subgroup meta-analyses were made as the interventions included diverse in structure, delivery and theoretical underpinning. However, the certainty of evidence regarding the effectiveness of each intervention was deemed very low due to several factors.</p> <p>While most studies utilized validated indices to measure plaque and gingival inflammation, enabling meta-analysis and pooling of effect estimate; the absence of control groups in most studies makes it difficult to ascertain whether the observed improvements are attributable to psychological behavioural therapy or merely to repetition and reinforcement ([<reflink idref="bib11" id="ref258">11</reflink>]). In addition, the small reduction and large standard deviation in plaque and gingival inflammation scores raise uncertainty about the clinical significance of these interventions. Nevertheless, these psychological behavioural interventions improve communication and enhance dialogue between autistic children with healthcare professionals, enabling oral health reinforcement and initiative behavioural change to be delivered in a way that more easily understood by the recipients ([<reflink idref="bib41" id="ref259">41</reflink>]). This fosters rapport among patients, parents, and dental professionals. Nevertheless, these psychological behavioural interventions improve communication and facilitate dialogue between autistic children with healthcare professionals, thereby supporting oral health reinforcement and promoting behavioural change in a manner that is more easily understood by the recipients ([<reflink idref="bib41" id="ref260">41</reflink>]). This approach helps foster rapport among patients, parents, and dental professionals, but additional research is necessary to elucidate the underlying mediating mechanisms.</p> <p>VM has shown superiority over VP in the two of the four included studies, particularly when interacting with autistic children who might face more challenges in social communication. Videos may offer a more detailed and direct approach to reducing imaginative barriers and helping autistic children understand the correct toothbrushing techniques. However, the variety of videos and VPs used across the included studies was notable, with some employing social stories featuring real pictures, others using cartoons and drawings, and a range of video formats including those with real individuals, older children, or cartoons, with narrative audio or muted. Uncertainty exists regarding the validation of these materials before implementation, which could impact their effectiveness in conveying the intended message.</p> <p>Furthermore, differences in reinforcement frequency across studies may contribute to the significant heterogeneity found in the meta-analyses. Most studies assigned the reinforcement task to parents or caregivers, potentially introducing a confounding factor. Parents with limited oral health awareness may affect reinforcement frequency and implementation consistency of the intervention materials, as well as the oral hygiene status of their children ([<reflink idref="bib42" id="ref261">42</reflink>]). Higher parental educational status has been positively correlated with better responses to behavioural therapy, as well as improved oral health in their children. Given the key role that parents and caregivers play in delivering behavioural therapy and influencing oral health outcomes ([<reflink idref="bib7" id="ref262">7</reflink>]; [<reflink idref="bib17" id="ref263">17</reflink>], [<reflink idref="bib18" id="ref264">18</reflink>]), further research is needed to control for or evaluate parental factors in the effectiveness of behavioural interventions aimed at improving oral health.</p> <p>Additional confounding variables include the severity of ASD, intellectual abilities, and cognitive functions of the recipients ([<reflink idref="bib16" id="ref265">16</reflink>]), which were often not reported or controlled for in the included studies. Moreover, the significant conceptual and statistical heterogeneity observed may be attributable to the inclusion of studies with markedly different designs, ranging from observational studies to randomized and quasi-randomized controlled trials. While this approach broadens the scope of the review, it also limits the robustness of any pooled analyses. However, further stratified analysis, subgroup analyses by study design or risk of bias and sensitivity analysis were not possible due to limited number of studies found. All results regarding the benefits of psychological behavioural therapies should be interpreted with caution due to the very low certainty of evidence, and their clinical applicability should not be overstated.</p> <p>It is intriguing that one of the studies included in the analysis revealed that yoga could enhance the toothbrushing skills and oral hygiene of autistic children. Yoga is acknowledged as an alternative therapy that can enhance motor skills and manual dexterity in individuals with autism, offering a possible explanation for its effectiveness in improving the oral hygiene of autistic children ([<reflink idref="bib33" id="ref266">33</reflink>]). Moreover, yoga and other exercises have been found to boost socio-emotional functioning, cognition, and attention ([<reflink idref="bib2" id="ref267">2</reflink>]), potentially assisting the completion of daily tasks like toothbrushing. However, the findings were based on non-randomized studies where interventions were allocated by school as a unit. It is important to acknowledge the potential bias stemming from clustering effects in these study designs. Therefore, it is advisable to interpret such results with caution and advocate for further research in this area.</p> <p>The certainty of the evidence was very low due to several factors. The studies were based on small sample sizes, associated with a high risk of bias, and were susceptible to potential deviations from the intended outcomes as they relied significantly on caregivers' delivery without strict frequency control. In addition, the psychological behavioural therapies utilized in the studies were not clearly validated according to established psychological therapy standards. The presence of significant heterogeneity in measurement and reporting further complicated the pooling of data for meta-analyses. In addition, most studies lack long-term follow-up, which limits the ability to assess the durability of oral health improvements among autistic individuals due to the absence of retention data. Future research should incorporate longer follow-up periods to better evaluate the sustainability of oral health outcomes resulting from behavioural therapies.</p> <p>Limitations of the review process include the exclusion of studies without full English text, however, no relevant studies were excluded on this basis, as all included studies were available in English. Moreover, exclusion of non-English article was not expected to have a substantial impact on the overall findings ([<reflink idref="bib20" id="ref268">20</reflink>]). Publication bias was not assessed due to limited number of relevant studies identified. In instances where raw data was unavailable in a minority of included reports, authors were not contacted for this information for meta-analysis, and the results were instead reported narratively. However, due to the heterogeneity in reporting and study conduct, synthesizing the data for meta-analysis may not have been appropriate, and a narrative presentation was considered more appropriate.</p> <hd id="AN0188761506-21">Conclusion</hd> <p>Psychological therapies such as visual pedagogy and video modelling showed some benefits in improving the oral health of autistic children and adolescents, but the certainty of evidence was very low. Further research with more rigorous study designs, particularly focusing on the development, validation, and implementation of psychological therapies, is necessary to draw stronger conclusions regarding the effectiveness of such therapies among autistic children.</p> <hd id="AN0188761506-22">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-aut-10.1177_13623613251372276 for Application of psychological behavioural therapies in improving oral health for children and adolescents with autism spectrum disorder: A systematic review and meta-analysis by Phoebe PY Lam, Elise Hoi Wan Fok, Megan Yuen Tung Chan, Colman Patrick McGrath and Cynthia Kar Yung Yiu in Autism</p> <hd id="AN0188761506-23">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-2-aut-10.1177_13623613251372276 for Application of psychological behavioural therapies in improving oral health for children and adolescents with autism spectrum disorder: A systematic review and meta-analysis by Phoebe PY Lam, Elise Hoi Wan Fok, Megan Yuen Tung Chan, Colman Patrick McGrath and Cynthia Kar Yung Yiu in Autism</p> <hd id="AN0188761506-24">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-3-aut-10.1177_13623613251372276 for Application of psychological behavioural therapies in improving oral health for children and adolescents with autism spectrum disorder: A systematic review and meta-analysis by Phoebe PY Lam, Elise Hoi Wan Fok, Megan Yuen Tung Chan, Colman Patrick McGrath and Cynthia Kar Yung Yiu in Autism</p> <p>We greatly appreciate the indispensable help in statistical analyses received from Ms Samantha Li, the statistician of Faculty of Dentistry, The University of Hong Kong.s</p> <ref id="AN0188761506-25"> <title> References </title> <blist> <bibl id="bib1" idref="ref35" type="bt">1</bibl> <bibtext> Aljubour A., AbdElBaki M., El Meligy O., Al Jabri B., Sabbagh H. 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After using this tool, the authors further reviewed and edited the content as needed and take full responsibility for the content of the publication.</bibtext> </blist> <blist> <bibtext> Phoebe PY Lam</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-2468-2080 Megan Yuen Tung Chan</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0009-0009-6568-2261 Cynthia Kar Yung Yiu</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0003-4090-6205</bibtext> </blist> <blist> <bibtext> The study is a systematic review with data generated from published articles. Ethical approval is not applicable as there was no human subject involved.</bibtext> </blist> <blist> <bibtext> Phoebe PY Lam: Conceptualization; Data curation, Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing–original draft; Writing–review & editing.Elise Hoi Wan Fok: Data curation; Formal analysis; Investigation; Methodology; Software; Validation; Writing–review & editing.Megan Yuen Tung Chan: Data curation; Formal analysis; Investigation; Methodology; Software; Validation; Writing–review & editing.Colman Patrick McGrath: Conceptualization; Resources; Supervision; Writing–review & editing.Cynthia Kar Yung Yiu: Conceptualization; Funding acquisition; Supervision; Writing–review & editing.</bibtext> </blist> <blist> <bibtext> The authors disclosed receipt of the following financial support for the research; authorship; and/or publication of this article: The project received funding from the Early Career Scheme of Research Grants Council, Hong Kong Government Special Administrative Region (Project no. 27100224).</bibtext> </blist> <blist> <bibtext> The authors declared no potential conflicts of interest with respect to the research; authorship; and/or publication of this article.</bibtext> </blist> <blist> <bibtext> Data from this study can be shared upon a valid request made to the corresponding author.</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> </ref> <aug> <p>By Phoebe PY Lam; Elise Hoi Wan Fok; Megan Yuen Tung Chan; Colman Patrick McGrath and Cynthia Kar Yung Yiu</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib35" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib22" firstref="ref4"></nolink> <nolink nlid="nl3" bibid="bib13" firstref="ref8"></nolink> <nolink nlid="nl4" bibid="bib39" firstref="ref9"></nolink> <nolink nlid="nl5" bibid="bib28" firstref="ref13"></nolink> <nolink nlid="nl6" bibid="bib27" firstref="ref14"></nolink> <nolink nlid="nl7" bibid="bib37" firstref="ref15"></nolink> <nolink nlid="nl8" bibid="bib16" firstref="ref16"></nolink> <nolink nlid="nl9" bibid="bib12" firstref="ref18"></nolink> <nolink nlid="nl10" bibid="bib32" firstref="ref19"></nolink> <nolink nlid="nl11" bibid="bib36" firstref="ref20"></nolink> <nolink nlid="nl12" bibid="bib40" firstref="ref21"></nolink> <nolink nlid="nl13" bibid="bib38" firstref="ref22"></nolink> <nolink nlid="nl14" bibid="bib30" firstref="ref34"></nolink> <nolink nlid="nl15" bibid="bib10" firstref="ref39"></nolink> <nolink nlid="nl16" bibid="bib14" firstref="ref40"></nolink> <nolink nlid="nl17" bibid="bib19" firstref="ref41"></nolink> <nolink nlid="nl18" bibid="bib21" firstref="ref42"></nolink> <nolink nlid="nl19" bibid="bib23" firstref="ref43"></nolink> <nolink nlid="nl20" bibid="bib24" firstref="ref44"></nolink> <nolink nlid="nl21" bibid="bib25" firstref="ref45"></nolink> <nolink nlid="nl22" bibid="bib26" firstref="ref46"></nolink> <nolink nlid="nl23" bibid="bib29" firstref="ref47"></nolink> <nolink nlid="nl24" bibid="bib31" firstref="ref48"></nolink> <nolink nlid="nl25" bibid="bib34" firstref="ref49"></nolink> <nolink nlid="nl26" bibid="bib42" firstref="ref50"></nolink> <nolink nlid="nl27" bibid="bib15" firstref="ref101"></nolink> <nolink nlid="nl28" bibid="bib11" firstref="ref258"></nolink> <nolink nlid="nl29" bibid="bib41" firstref="ref259"></nolink> <nolink nlid="nl30" bibid="bib17" firstref="ref263"></nolink> <nolink nlid="nl31" bibid="bib18" firstref="ref264"></nolink> <nolink nlid="nl32" bibid="bib33" firstref="ref266"></nolink> <nolink nlid="nl33" bibid="bib20" firstref="ref268"></nolink>
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  Data: <searchLink fieldCode="DE" term="%22Dental+Health%22">Dental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Hygiene%22">Hygiene</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Modification%22">Behavior Modification</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Psychoeducational+Methods%22">Psychoeducational Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Research%22">Research</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/13623613251372276
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1362-3613<br />1461-7005
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: This systematic review aimed to summarize the current evidence on the effectiveness of various psychological behavioural therapies in improving oral hygiene maintenance habits and oral health among children with autism. Independent screening and study selection, data extraction, risk of bias assessment, and evaluation of the certainty of evidence were conducted. A total of 16 studies were deemed eligible for qualitative synthesis, with 9 included in quantitative analyses. Psychological behavioural therapies including visual pedagogies, social stories, components of PECS (Picture Exchange Communication System) and Applied Behavioural Analysis, as well as the use of smart device applications all demonstrated improvement in oral health parameters following implementation. However, most studies lacked control groups and exhibited a high risk of bias due to the lack of reporting or failure to account for autism spectrum disorder (ASD) severity and associated comorbidities. In addition, studies typically relied on caregivers to carry out reinforcement of therapies, which may explain the significant heterogeneity observed. In summary, the evidence supporting the use of psychoeducational techniques to improve the oral health parameters of autistic children is limited and of very low certainty. Further research utilizing larger-scale studies and more rigorous study designs is necessary to enhance the certainty of evidence in this field.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1487094
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1487094
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/13623613251372276
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 15
        StartPage: 2662
    Subjects:
      – SubjectFull: Dental Health
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Hygiene
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Behavior Modification
        Type: general
      – SubjectFull: Program Effectiveness
        Type: general
      – SubjectFull: Psychoeducational Methods
        Type: general
      – SubjectFull: Research
        Type: general
      – SubjectFull: Health Behavior
        Type: general
    Titles:
      – TitleFull: Application of Psychological Behavioural Therapies in Improving Oral Health for Children and Adolescents with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Phoebe P. Y. Lam
      – PersonEntity:
          Name:
            NameFull: Elise Hoi Wan Fok
      – PersonEntity:
          Name:
            NameFull: Megan Yuen Tung Chan
      – PersonEntity:
          Name:
            NameFull: Colman Patrick McGrath
      – PersonEntity:
          Name:
            NameFull: Cynthia Kar Yung Yiu
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 11
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1362-3613
            – Type: issn-electronic
              Value: 1461-7005
          Numbering:
            – Type: volume
              Value: 29
            – Type: issue
              Value: 11
          Titles:
            – TitleFull: Autism: The International Journal of Research and Practice
              Type: main
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