Sensory Integration Education

Sharon A. Cermak, Ed.D., OTR/L, FAOTA and Marinthea Richter, MA, OT share their work on this exciting project which is continuing to expand across client populations. The SIE team had the pleasure of meeting Sharon at both the AOTA conference and at the ESIC where we connected, shared ideas and discussed her research which she has detailed below.

Going to the dentist does not often make it to the top of any “fun things to do” list. The sound of the dental equipment, the sensation of the materials in and around the mouth and the bright lights and occasional strange chemical smells is enough to make anyone apprehensive. Now imagine how this experience is perceived by children who are hypersensitive to sensory input. Children with Autism Spectrum Disorder (ASD) have a high rate of co-occurring challenges in sensory processing which negatively affects their oral care (Stein, Polido, & Cermak, 2013).

They may become overwhelmed by everyday sensory experiences that may not bother typically developing children, resulting in increased self-stimulation and negative behaviors that may make oral care extremely challenging for the dental team and traumatic for the children and their family. As such, many dentists are not willing to treat children with ASD making it difficult for families to find a dentist. Ensuring good oral hygiene for children is crucial to overall health and well-being, however it may be difficult to ensure adequate care for children with ASD given their behavioral challenges. As a result, some children need pharmacological measures such as general anaesthesia for oral care. However, the risk and cost of performing routine preventative dental care under general anaesthesia may preclude this option for many children with ASD. As such, innovative approaches to oral care are needed.

Initial research into Sensory Adapted Dental Environments (SADE) for children with developmental disabilities was conducted by Dr. Michele Shapiro from Beit Issie Shapiro Centre in Israel. This study found that SADE could potentially be an important consideration for dental cleaning as it helped to enhance cooperative behavior and relaxation of 16 children with developmental disabilities (Shapiro, Melmed, Sgan-Cohen, & Parush, 2009).

Dr. Sharon Cermak (EdD), a professor at the Chan Division of Occupational Therapy and Occupational Science at the University of Southern California (USC) was inspired by the work done by Dr. Shapiro and secured a grant from the National Institute of Dental and Craniofacial Research (NIDCR) to conduct a pilot and feasibility pilot study using SADE with children with ASD to examine whether SADE reduces physiological anxiety, behavioral distress and subjective pain during dental cleaning. The research was done in collaboration with an interdisciplinary team including Dr. Jose Polido, DDS, Director of the Dental Clinic at Children’s Hospital Los Angeles (CHLA) and Associate Professor at the Ostrow School of Dentistry USC, Marian Williams, Ph.D., a clinical psychologist at the USC University Center for Excellence in Developmental Disabilities at CHLA and Michael Dawson, PhD, a psychologist with expertise in Electrodermal Activity measures at USC.

The pilot and feasibility study included 44 participants (22 children with ASD and 22 typically developing children) between the ages of six and twelve years. The children each had two dental visits (four months apart), one in a regular dental office without any adaptations and one in the same dental office but with sensory environmental modifications. The modifications included playing soothing music (a mixture of classical music and nature sounds) in the background, dimming the overhead fluorescent lights, projecting soft moving images (“blue or purple lava lamp bubbles” or swimming fish) onto the ceiling, and having the dentist use a dentist headlamp rather than the large dental light. In addition, the dental chair had a cover on it with a butterfly with wings that attached to the side of the chair. An X-ray bib was placed over the child and the wings of the butterfly wrapped around the child’s body providing a deep pressure hug. These modifications were designed to decrease the child’s anxiety.  

Two electrodes were placed on the child’s fingers and we recorded electrodermal activity (EDA) before, during, and after the dental cleaning to determine the children’s physiological anxiety levels. We also video-recorded the child during the cleaning and coded it for child distress. Children completed subjective evaluations of pain and sensory discomfort after the dental cleaning and the dentist rated levels of cooperation. Both groups of children had reduced subjective pain levels, reduced anxiety, and found the SADE environment more comfortable (Cermak et al., 2015). These results were encouraging as it showed that SADE might be beneficial for both neurotypical children and children with ASD, although the ASD group demonstrate greater benefits than the typically developing children. The children with ASD also required fewer people to restrain them during the cleaning in the SADE compared to the regular dental environment. This implies lower costs for care if fewer people are needed to provide the care. 

With these exciting results, Dr. Cermak applied for a large grant from the NIDCR to launch a full-scale randomized control trial. A larger sample would provide better information about the effectiveness of SADE and enable the researchers to look at moderating variables such as the child’s age, autism severity, and IQ, and also look at mediating variables to better understand causal mechanisms. This study was funded by NIH and is currently underway with more than 200 participants with ASD enrolled in the study. The team also added an economist to the team, Dr. Joel Hay, Professor of Pharmaceutical and Health Economics at USC, to examine cost effectiveness of the intervention. The research team at CHLA and USC is currently hard at work collecting the data and are eagerly awaiting the results.

The SADE research has opened the door for wonderful collaboration between occupational therapists and dental professionals. Looking at the environmental enhancement from a sensory perspective is an emerging area of occupational therapy practice. Occupational therapists have a wealth of knowledge about sensory processing and understand how sensory input from the environment can influence the participation of people with sensory sensitivities. This multidisciplinary research has given the professionals involved the opportunity to critically examine the often overlooked role of environmental design within health care and discuss how we can adapt settings to allow enhanced participation of children and adults with disabilities. We have extended our work to include suggested modifications to waiting rooms, at oncology units, and in emergency rooms. Environmental modifications have great potential to allow better access for children with ASD to dental care. As the dental environment is more welcoming, we expect that children will be less anxious and show more cooperative behaviour. In turn, parents will be less apprehensive about scheduling return visits to the dentist, and dentists might be more willing to serve children with ASD and other disabilities. These factors will improve oral health for children with ASD.  

Research in this area is ongoing and expanding. In a supplemental study, Dr. Cermak and her team received funding to conduct a feasibility study of SADE with children with Down Syndrome. Dr. Cermak believes that this research has the potential to revolutionize the manner in which children with disabilities receive oral health care services not only in the United States of America but around the globe.