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Year : 2021  |  Volume : 39  |  Issue : 1  |  Page : 2-8

The effect of multisensory-adapted dental environment on children's behavior toward dental treatment: A systematic review

1 Department of Paediatric Dentistry and Dental Public Health, Kulliyyah of Dentistry, International Islamic University Malaysia; Department of Dental and Maxillofacial Surgery, Sultan Ahmad Shah Medical Centre, International Islamic University Malaysia, Pahang, Malaysia
2 Kulliyyah of Dentistry, International Islamic University Malaysia, Pahang, Malaysia
3 Department of Preventive Dental Science, College of Dentistry, AlMajmaah University, Majmaah, Saudi Arabia

Date of Submission27-Jan-2021
Date of Decision01-Mar-2021
Date of Acceptance02-Mar-2021
Date of Web Publication22-Apr-2021

Correspondence Address:
Dr. Ahmad Faisal Ismail
Department of Paediatric Dentistry and Dental Public Health, Kulliyyah of Dentistry, International Islamic University Malaysia, Kuantan Campus, Pahang
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisppd.jisppd_36_21

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Objective: The objective was to assess the effectiveness of multisensory-adapted environment on children's behavior toward dental treatment, specifically in special need children. Materials and Methods: The main health databases were selected such as SCOPUS, Medline, CINAHL, and Dentistry and Oral Sciences. A set of keywords was defined to identify the relevant article were (i.e., Snoezelen OR Multisensory OR sensory-adapted and Dentistry OR Oral). The articles were selected and extracted by two reviewers based on the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines and some predetermined exclusion criteria. Furthermore, the risk of bias assessment was done. Results: A total of 317 papers were selected at the first phase from SCOPUS (97 papers), Medline (108 papers), CINAHL (110 papers), and Dentistry and Oral Sciences (2 papers). After applying the inclusion and exclusion criteria and duplicated papers were removed, only four eligible papers were selected for final synthesis. Conclusions: Multisensory-adapted dental environment effectively improves oral health behavior among special needs children in terms of physiological changes, behaviors, pain, and sensory discomfort. Thus, the clinician may introduce this approach in their clinical settings.

Keywords: Dentistry, multisensory, oral hygiene, sensory-adapted

How to cite this article:
Ismail AF, Tengku Azmi TM, Malek WM, Mallineni SK. The effect of multisensory-adapted dental environment on children's behavior toward dental treatment: A systematic review. J Indian Soc Pedod Prev Dent 2021;39:2-8

How to cite this URL:
Ismail AF, Tengku Azmi TM, Malek WM, Mallineni SK. The effect of multisensory-adapted dental environment on children's behavior toward dental treatment: A systematic review. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Sep 17];39:2-8. Available from: https://www.jisppd.com/text.asp?2021/39/1/2/314360

   Introduction Top

Impairment is defined as any temporary or permanent loss of body structure and function; meanwhile, disability is defined as a lack of ability to perform an activity normally due to, usually, impairment.[1] In conjunction with that, children with special needs are children with impairment or limiting conditions that prevent them from performing daily self-maintenance activities or full participation in their age group.[2] According to the National Educational Association of Disabled Students,[3] special needs can be divided into physical disabilities, learning disabilities, mental disabilities, hearing disabilities, visual disabilities, and neurological disabilities.

Children with special needs have higher chances of developing oral diseases due to the limitations imposed by their disabling condition. Their susceptibility to the development of dental caries and periodontal diseases can lead to dental pain and early tooth loss that can impact their overall quality of life.[4] It has been reported in a few studies that special needs children exhibit a poor oral hygiene status, reflecting their inadequate daily oral care.[4],[5] The reason identified for this is that special needs children face more challenges to practice proper oral hygiene and health care. This is most likely due to their inadequate manual dexterity and intellectual abilities that hinder good oral care practices such as brushing teeth.[6]

Several nonpharmacological therapies are suggested to reduce maladaptive behaviors and improve oral hygiene care among special needs children. A distinct therapy method that is gaining much attention is multisensory stimulation. The multisensory-stimulating environment, which is usually presented in a pleasurable and relaxing space known as the “Snoezelen room” is proposed as an effective therapy in treating individuals with learning disabilities.[7] The Snoezelen room, which was created in the early 1970s, was the brainchild of two therapists working at an institution for persons with developmental disabilities.[8] The term “Snoezelen” is a contraction of two Dutch words; snuffles, which means to sniff out or explore one's environment, and “doezelen,” which denotes to doze or relax.[9] In general, the Snoezelen multisensory therapy is a well-equipped room to incorporate all of the human senses by combining a well-illuminated room with good lighting, mesmerizing sound, vibration, and aroma, along with good tactile sensation. Although the setting-up of a Snoezelen room is expensive, it is essential to demonstrate the advantages of multisensory therapy compared to other nonpharmacological treatments available.[7]

Many studies regarding multisensory therapies that were done in the past that focused more on adults compared to children reported inconsistencies in the findings between both subjects. While several studies that involved adults with developmental disabilities showed that the utilization of the multisensory therapy leads to a positive effect on mental states, some others denoted that the therapy did not improve the negative behavior. On the other hand, several studies involving children proposed that multisensory environment therapy could induce appropriate response, relaxation, and reduce agitation and anxiety.[10] Thus, this systematic review was carried out to assess the effectiveness of a multisensory-adapted environment in improving oral health among special needs children. It is hypothesized that the children exposed to the multisensory therapy exhibited better oral hygiene, and this hypothesis may support the findings from previous studies.

   Materials and Methods Top

The study method, which comprises protocol selection, a search based on inclusion and exclusion criteria, and data analysis, is outlined hereafter. About the protocol used, the Preferred Reporting Items for Systematic Review and Meta-analysis 2015, intended primarily for the preparation of systematic review and meta-analysis, was applied as the protocol for this review.[11] Furthermore, the search strategy involved a thorough search of data that was not limited to any range of years from several electronic databases such as “SCOPUS”, “Medline”, “CINAHL,” and “Dentistry and Oral Sciences.” The leading search keywords used to identify the relevant article were ((multisensory OR sensory adapted) AND (dentistry OR oral)). Studies that met the inclusion criteria were critically appraised by two researchers independently. All the identified records were scanned by title and abstract. The studies were selected based on titles and abstracts identified from the databases and hand search. The full-text review was retrieved and examined when their title and summary did not provide enough information for a decision. A standardized form comprised the variables of interest used for data extraction. In case of discrepancy, the paper was discussed by all authors until consensus reached. The articles appearing in more than one database were considered only once. The eligibility criteria for the selection of relevant data include studies that discussed the benefits of a multisensory-adapted environment, which were then selected based on the predetermined inclusion and exclusion criteria. The inclusion criteria used in this review were as follows: (i) should consist of multisensory or sensory adapted environment, (ii) should only include human studies, (iii) must be published in the English language, (iv) a title with abstract is available, and (v) can include either adolescent or adult as the subject. Meanwhile, the exclusion criteria included the following: (i) nonhuman studies, (ii) review article or letter to the editor, and (iii) articles without an abstract. The Cochrane Collaboration's tool used for assessing the risk of bias was used to perform the quality analysis and the risk of bias in the included studies.[12]

   Results Top

The initial database search resulted in 317 articles. After extraction of the required information, 263 articles were eliminated based on the exclusion criteria in the breakdown of no abstract available (n = 45), nondental related (n = 139), review articles (n = 67), letters to the editor (n = 3), and non-English language paper (n = 9). Following that, the remaining 54 full article titles and abstracts were screened to assess their relevance and validity. After a thorough examination of the selected articles, another 10 articles were removed due to duplication, and 4 articles were excluded as they were review papers. Another 34 and 2 articles were excluded as they were nondental related and non-English articles, respectively. The search and selection carried out by three reviewers, finally resulted in four research articles for data extraction to be included in the review. As consensus among reviewers was important for the articles involved in the final analysis and synthesis, all reviewers agreed that the four articles[13],[14],[15],[16] should be included for the final analysis. The summary of retrieved, excluded and included articles are summarized in [Figure 1]. The details of the finally included four studies are summarized in [Table 1]. Subsequently, these four articles were examined in detail to extract the remaining information based on the selection criteria, and the data extracted were processed. Three studies from Israel[13],[14],[15] and another study[16] is from the United States of America, and three studies from the same authors. Two articles[13],[14] were published in dental journals and the rest two[15],[16] were published in medical journals. The objective and findings of the four studied are shown in [Table 2]. Shapiro et al. studied the efficacy of a Snoezelen sensory adapted dental environment (SDE) in 19 children planned for calculus removal by hygienists.[13] The authors observed at the visual sensation, audio and somato sensor, and tactile in their study population. The Snoezelen environment consists of a partially dimmed room with lighting effects, vibroacoustic stimuli, and deep pressure. In an American study, the authors examined SDE's impact to minimize sensory discomfort, distress, and perception of pain during oral prophylaxis among the autistic children. In another study,[14] the authors looked at adapted environment influence on the anxiety levels among the medically treated children with developmental disability. The authors found a greater difference between SDE and regular environment, and children with developmental disabilities (CDD) would benefit from SDE. The same group of authors[15] evaluated the effect of SDE on anxiety, relaxation, and cooperation of 16 CDD. The authors found that SDE is best for these children for oral hygiene practices. An American group piloted a study[16] with 44 children to examine the impact of SDE, and the authors found that the SDE is more beneficial compared to the regular environment. The Cochrane risk of bias tool showed low risk in all the studies [Figure 2], and two studies used the same methodology with different outcomes.[13],[14] The level of risk has been exhibited in [Figure 3].
Table 1: Details of included studies for the final analysis

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Figure 1: Preferred Reporting Items for Systematic Review and Meta-analysis flow chart of study design

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Table 2: Objectives and findings from the final included studies

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Figure 2: Risk of bias summary: Review authors' judgments about each risk of bias item for each included study

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Figure 3: Risk of bias graph: Review authors' judgments about each risk of bias item presented as percentages across all included studies

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   Discussion Top

Based on the analysis, the four studies showed that the sensory-adapted dental environment affects the children's physiological arousal. This parameter was evaluated by assessing the graph of the mean results of electrodermal activity (EDA), the degree of arousal (average troughs), and the degree of relaxation (average peaks). A random crossover study design was applied, where one group of patients was initially treated under the SDE and moved to a regular dental environment (RDE). In contrast, the other group received treatment under RDE before receiving SDE. The results found that mean EDA was significantly reduced in SDE compared with RDE, indicating that patients were in a state of lower arousal. However, there was no significant effect on the sequence from this crossover design study. On the other hand, the degree of arousal is significantly higher in the RDE group than in the SDE group. Still, the degree of relaxation was observed to be marginally higher but insignificant in the SDE group.[13]

A similar study was done to assess the effects of the application of Snoezelen therapy on CDD. This study found that the mean EDA was significantly reduced while the degree of relaxation. However, it was considerably greater in SDE compared to RDE, did not indicate any significant difference in the degree of arousal. This shows that CDD is more relaxed in the SDE as compared to RDE.[12] Another study measured the tonic EDA (baseline) before treatment and phasic EDA during the treatment of two different groups, CDD and typical children. The EDA measurement was higher (more relaxed) in the SDE group as compared to the RDE group. Regardless of the environment, the overall EDA measurement was higher in CDD compared to typical children. Similar results were seen in the phasic EDA during treatment as the data revealed a significant effect of environment where both groups were noted to be more relaxed in the SDE rather than the RDE. In this study, the authors stated that the overall, CDD exhibited a greater degree of relaxation compared to typical children in both environment.[14]

Additionally, a study was done to compare two groups consisting of children with autism spectrum disorder (ASD) and typically developing (TD) children in both SDE and RDE. Both groups showed a decrease in EDA in SDE compared to RDE. Further, a significant difference that existed between the ASD and TD group for all EDA measures indicated that the ASD group exhibited more significant effects of relaxation compared to the typically developing children.[16] Beyond doubt, the adapted sensory environment also seemed to affect the children's behavior, as mentioned in all four articles. Shapiro et al. employed the general anxiety scale (GAS) questionnaire for parents to rate on a scale of 1–4 (1 = extremely anxious to 4 = relaxed) their child's general anxiety in a new place, with new people, and indifferent dental situations. The results showed that general anxiety was uncommon among these children.[13] One child had anxiety, particularly in new places, two with above-average general anxiety, and another ten children with dental anxiety. Additionally, the negative dental behavior checklist, which was also used to evaluate their behavior, found that the number of anxious behaviors had significant effects on the sequence of therapy where the numbers were reduced in patients who initially received SDE before RDE as compared to those who received RDE first. However, the mean number of anxious behaviors showed no significant reduction in SDE compared to RDE, indicating that there was no significant effect of the treatments. On the contrary, the duration and magnitude showed insignificant sequence effects. Still, a substantial impact on treatment was evidence, indicating a notable decrease in the anxiety duration and magnitude. Moreover, the anxiety and cooperation scale ranging between 0 and 5, whereby the scale 0 represents extreme behaviors, and 5 denotes relaxed behavior, showed no significant sequence effect but a significant treatment effect. The children also showed improved cooperation in the SDE in contrast to RDE.

Besides that, the behavior of CDD can also be improved in a Snoezelen environment as shown in a study.[14] This study's findings, particularly the mean duration and magnitude of anxious behavior, reported a significant reduction in SDE compared to RDE. However, the mean number of behaviors showed no considerable reduction, similar to previous studies' findings. The cooperation levels were recorded in the SDE and significantly higher than in the RDE. As aforementioned, the study that compared the CCD with typical children found that both groups showed a shorter duration of anxious behavior in SDE than the RDE. However, in both SDE and RDE, CCD exhibited a more extended period of anxious behavior than typical children.[15]

Furthermore, a study found that the pain intensity and sensory discomfort during dental treatment can be minimized with a sensory-adapted environment in the dental operatory.[16] The required parameters were analyzed through child-report measures of pain intensity and sensory discomfort. The faces pain scale consists of drawings of six faces that express increasing distress, and the dental sensory sensitivity scale was used to analyze the pain intensity and sensory discomfort. The findings noted a significant improvement in both the ASD and TD groups in SDE. This shows that the sensory stimulation provides physiological and behavioral improvement and helps manage the pain and discomfort during dental treatments among children. Besides, the study also elaborated on the cost element when treating the patient in an SDE. One of the measures used to study the costing effect was the duration of the dental cleaning procedure which was significantly longer in SDE. This is contradictory to the notion that SDE can reduce the cost as more extended treatment would increase treatment price. The second measure used was the number of hands required to restrain the child during the dental procedure, which was significantly reduced in SDE as compared to RDE. Meanwhile, another measure which was the requirement for pharmacological methods to complete dental treatment demonstrated inconclusive results as none of the children required any pharmacological intervention. However, some children in the ASD group had a history of requiring general anesthesia during treatment. Two limitations had been identified in this review. The first limitation was due to limited search engines as this review went through only four search engines that gave us a limited number of articles on related topics. Thus, it is suggested to have a large number of databases or search engines in order to require related articles as much as possible. The second limitation of this review was the small sample size. We had only four eligible articles related to the topic, which precluded us from achieving more convincing results. Therefore, a large sample size in future studies will permit us to achieve a more effective result in terms of the effectiveness of multisensory-adapted environment on special needs children.

Clinical relevance

As multisensory-adapted dental environment is deemed to be effective in managing anxious children, especially in special need children, clinicians are recommended to apply some modification in their clinical settings. For instance, in reducing visual discomfort, clinicians may place dark curtains on the windows, turn out all the direct dental lamp, display slow-moving color effect on the ceiling and use a head-mounted lamp directed into the patient's mouth. Meanwhile, setting up portable speakers to play rhythmic music can reduce auditory distraction in anxious children. Lastly, butterfly-like wrap with X-ray vest on children chest can give a hugging effect as well as promote tactile sensation throughout the dental procedure.[16]

   Conclusions Top

Multisensory-adapted dental environment effectively improves oral health behavior among special needs children in terms of physiological changes, behaviors, pain, and sensory discomfort. There is a need for more studies with a large sample size to establish the effect of multisensory-adapted dental environment on children's behavior toward dental treatment.

Financial support and sponsorship

This review was supported by IRF19-015-0015.

Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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