Strategies To Reduce the Use of General Anesthesia for Children and Adolescents With Special Health Care Needs: Dental Desensitization and 'Shorten the Line' Models

Jean Calvo, DDS, MPH, is an assistant clinical professor in the division of pediatric dentistry at the University of California, San Francisco, School of Dentistry. Conflict of Interest Disclosure: None reported.

Paul Glassman, DDS, MA, MBA, is a professor and associate dean for research and community engagement at the California Northstate University, College of Dental Medicine in Elk Grove, Calif. Conflict of Interest Disclosure: None reported.

Tara Glavin, MA, BCBA, is a board-certified behavior analyst at the UCSF Center for ASD & NDDs, department of psychiatry at the University of California, San Francisco. Conflict of Interest Disclosure: None reported.

Helen Mo, DMD, MS, is a volunteer assistant clinical professor, division of pediatric dentistry at the University of California, San Francisco. Conflict of Interest Disclosure: None reported.

ABSTRACT

Background: Providing access to preventive and restorative dental care for children and adolescents with special health care needs (SHCN) is an imperative step in improving and maintaining their overall health. Often children and adolescents with SHCN receive referrals for dental treatment with sedation or general anesthesia. However, many children who are currently referred for dental treatment using general anesthesia could have dental care using less invasive, costly and risky methods with a series of strategies in the community and dental setting.

Methods: The aim of this paper is to describe two models of reducing indications and referral for dental care with sedation and/or general anesthesia: a community-based comprehensive care system referred to as “shorten the line” and the use of desensitization in the dental setting.

Results: The “shorten the line” strategy is a system involving dental hygienists, dental assistants, care coordinators and behavior support specialists deployed in community locations such as preschools, schools, residential facilities and day programs. The dental desensitization model described in this paper integrates the use of telehealth, previsit imagery, interprofessional care, systematic desensitization, dental office accommodations and home oral health practice.

Conclusion: By implementing innovative models of care for patients with SHCN, it is possible to increase the completion of dental treatment for patients with SHCN in a community location or dental office rather than referring the patient for care with general anesthesia.

Practical implications: Dentists can implement interventions and adapt the ways in which they provide dental care to patients with SHCN to increase access to routine dental care for this population and reduce the number of patients requiring dental treatment with general anesthesia.

Keywords: Special health care needs, access to care, general anesthesia

__________

Children with special health care needs (CSHCN) is a term found in federal and state statutes and is used for program eligibility, measurement and reporting purposes. One definition of this term is, “Those who have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions. They also require health and related services of a type or amount beyond that required by children generally.” [1] This is a broad term that includes many types of conditions. Other overlapping and in some cases more specifically defined terms include ‘‘children with special needs,’’ ‘‘children with disabilities,’’ “children with developmental disabilities” and ‘‘children with complex conditions.’’ [2] The ideas discussed in this article can apply to children in any of these groups.

Providing access to preventive and restorative dental care for CSHCN is an imperative step in improving and maintaining their overall health. Special health care needs (SHCN) in children and adolescents span a wide array of domains, including behavioral, congenital, developmental and systemic diseases and disorders. [3] In California, an estimated 10% to 20% of individuals under age 21 have SHCN, [4] which commonly stem from asthma, attention deficit disorder, developmental delay, anxiety and autism spectrum disorder. [5]

A known consequence in CSHCN is an increased risk of dental caries. [6] Due to conditions such as cerebral palsy, autism spectrum disorder, congenital heart disease and trisomy 21, CSHCN have been shown to experience caries at a higher rate in both their primary and permanent dentition, compared with their non-SHCN peers. [7] Disappointingly, despite the increased risk and prevalence of dental disease in the pediatric SHCN population, the utilization of preventive dental care in individuals with SHCN is lower than it is in those without SHCN. [8]

The behavioral and medical conditions of CSHCN require individualized approaches to providing preventive and restorative dental care in this population. CSHCN can receive dental care in a variety of settings, such as schools, dental offices and hospitals, and through different modalities, such as behavior guidance, sedation and general anesthesia.

Many CSHCN receive referrals for dental treatment with sedation or general anesthesia. Furthermore, trends show that the use of general anesthesia for pediatric dental care is increasing. [9] Indications for general anesthesia can include medical conditions that require dental care to be completed in a controlled setting: lengthy, surgical or advanced dental procedures, which a child could not be expected to tolerate, and behavioral indications, such as severe anxiety and lack of cooperation. Some medical conditions of those with SHCN pose extreme risk during invasive dental procedures and eliminate the ability to render care in a non-hospital setting. Rendering of dental care to those with SHCN in any setting will often require consultation with the patient’s medical provider prior to care.

Completing dental treatment with general anesthesia offers many benefits, including the patient not being conscious during the procedure, thereby eliminating the need for patient cooperation, the dentist’s ability to complete more dental procedures at a time and the dentist’s ability to safely complete dental care in a controlled setting. However, general anesthesia also has associated risks, including mortality, and is the most medically invasive method of dental care. [10] Additionally, it is the costliest method of delivering dental care. [11] Furthermore, treatment of dental disease with general anesthesia in patients with SHCN is not a long-term solution to poor oral health, as CSHCN are likely to develop new caries following treatment and are likely to be treated multiple times with general anesthesia for dental care. [12]

As the use of general anesthesia for dental procedures is increasing, the proportion of children and adolescents with SHCN is large and only a limited number of providers can offer this type of specialized care. Hence, patients may have to wait several months or years in some areas to receive care with general anesthesia. [13,14] As a result, many children experience pain and reduced quality of life while waiting for care. The decision to provide dental care with general anesthesia should always include an individualized comprehensive evaluation of the indications, risks, benefits and alternatives to providing dental care in this way — and only be recommended when less invasive, risky and costly methods are not possible. [15]

The aim of this paper is to describe two models of reducing indications and referral for dental care with sedation and/ or general anesthesia: a community-based comprehensive care system referred to here as “shorten the line” and the use of desensitization in the dental setting.

Community-Based Comprehensive Care System (Shorten the Line)

Many CSHCN, particularly those with intellectual and developmental disabilities (IDD), are nervous in unfamiliar environments. In addition, some children with IDD have limitations in expressive language, which can be exacerbated at a time or in a location where they are nervous. A dental office or clinic is one environment where such an individual may be anxious and may be unable to adequately express their concerns or feelings. They may not be responsive to attempts to have them enter the office, sit in the waiting room, sit in a dental chair or allow any examination of their mouth. Consequently, this individual may be labeled as “uncooperative” and referred for dental treatment using sedation or general anesthesia. However, this same individual may respond differently in a more familiar environment.

Treatment of dental disease with general anesthesia in patients with SHCN is not a long-term solution to poor oral health.

Multiple decades of experience by some of the authors of this article have led to the conclusion that many children who are currently referred for dental treatment using general anesthesia could have dental care using less invasive, costly and risky methods with a series of strategies that are initiated in community sites prior to any interactions in a dental office or clinic.

The Special Care Dentistry Association published a consensus statement more than a decade ago about the use of sedation, anesthesia and alternative techniques for people with special needs. [16] That consensus statement described a number of nonpharmacological strategies that can reduce the need for sedation and general anesthesia but are underutilized because of limited training in their use, reimbursement mechanisms and consequent lack of availability. These interventions and strategies include behavior support, physical support, psychological support, social support and prevention strategies.

The College of Dental Medicine at California Northstate University (CNU), along with other partners, is developing a system to “shorten the line” to demonstrate the ability to reduce the number of individuals referred for dental treatment using general anesthesia. If some of the people currently referred for dental treatment using general anesthesia could have their dental needs met with nonpharmacological interventions and strategies, it could significantly reduce waiting times for those whose only option is general anesthesia. It would also lower costs to the health care system, reduce risk associated with pharmacological approaches and help “normalize” the experience of having dental care for these individuals.

CNU is developing a communitybased comprehensive care system as part of the shorten-the-line strategy. The system involves using dental hygienists, dental assistants, care coordinators and behavior support specialists deployed in community locations such as preschools, schools, residential facilities and day programs. The activities of these individuals are integrated with the Regional Center System, which is California’s social service system for people with developmental disabilities. [17] The primary strategies in the shortenthe-line system are described below.

A system to identify individuals at risk of being referred for dental treatment using sedation or general anesthesia: Individuals at risk can include those with a previous history of dental care using general anesthesia, a history of difficulty with office-based general health or dental care or a history of anxiety in unfamiliar environments.

Community-based behavioral, physical and psychological support: This includes an oral health team, including dental hygienists and assistants, working with care coordinators and behavior support specialists who are deployed in the community locations listed previously and perform behavior support interventions. These include desensitization and development of a behavior support plan and strategies.

Minimally invasive communitydelivered diagnosis, prevention and early intervention strategies: These interventions use the concepts of the virtual dental home system where dentists who are not on-site are able to use store-andforward asynchronous teledentistry systems to review records and perform a comprehensive examination, diagnosis and treatment plan. 18,19 The community team can perform traditional dental hygiene procedures, apply silver diamine fluoride and perform interim therapeutic restorations. In addition, they are trained to support the individual, parents and other caregivers in adopting “mouthhealthy habits,” the daily application of which is essential to good oral health.

Targeted referral and support for dental offices: After the desensitization, prevention, early intervention procedures and adoption of “mouth-health habits” are underway, a “warm handoff” referral can be made to a prepared and receptive dental office. These “targeted referrals” include matching the patient’s needs and situation to the training and capacity of the dental office and providing information on the patient’s health, behavioral and social history and the procedures for obtaining consent to care. It also involves a “warm handoff” of the behavioral support plan so personnel in the office can continue and expand on the strategies that have been working in the community environment.

These strategies are far more likely to result in a referral to a dental office that will lead to treatment in that office rather than a subsequent referral for dental care using general anesthesia.

Dental Desensitization To Increase Acceptance of Dental Care and Reduce Behavioral Indications for Dental Procedures With General Anesthesia

Every community may not have the support of a community-based comprehensive care shorten-the-line system. However, there are approaches that can be used that are centered at the dental office level that can also be beneficial in providing oral health services in an office environment rather than a referral for care using general anesthesia. These approaches include using telehealth for initial data gathering, pre-visit imagery and practice, use of behavior support professionals and office-based systematic desensitization.

Systematic desensitization is the gradual exposure of individuals to a stimulus or setting that they may be hypersensitive to or that may induce anxiety. The goal of systematic desensitization is to increase an individual’s tolerance and acceptance of a stimulus. Particularly, the pairing of relaxing or calm-inducing stimuli with the noxious stimulus can result in increased acceptance over time. [20] CSHCN may exhibit behaviors related to anxiety of hypersensitivity in the dental setting. This behavior is an unmodulated nervous system response to the stimuli of the dental setting and can lead to behavior that the dental provider perceives as uncooperative. While the use of general anesthesia to treat this type of patient will remove the need for the patient’s cooperation, it does not allow the patient to build long-term skills or the ability to accept dental care — and it does not contribute to the prevention of future dental disease.

Systematic dental desensitization has been shown to increase the acceptance of in-office dental routines among people with developmental disabilities — particularly those with neurodevelopmental disorders such as autism spectrum disorder (ASD), as this group of SHCN patients may have behavioral indications for dental treatment with general anesthesia without additional complex comorbidities. Dental desensitization is an evidencebased behavior support intervention that increases the acceptance of dental care among children. [21] Furthermore, unlike treatment with general anesthesia, dental desensitization allows children to learn to accept dental visits over time. [22]

One model of dental desensitization used at the UCSF Pediatric Dental Clinic integrates the use of telehealth, pre-visit imagery, interprofessional care, systematic desensitization, dental office accommodations and home oral health practice.

Integrating Telehealth Consultations and Dental Desensitization

An initial aspect of dental care for CSHCN is data gathering to understand the patients’ medical history and dental history. Furthermore, when implementing a dental desensitization approach, understanding the communication styles and behavioral needs of the patient is important. As physically being in the dental office can prove challenging to patients with SHCN, limiting the amount of non-treatment time spent in the dental setting can benefit them.

The use of secure telehealth tools to meet with parents/guardians of CSHCN prior to an in-office visit can allow for comprehensive data gathering without exposing patients to the anxiety of the dental setting. [23] At this initial telehealth consultation for parents/guardians of those with SHCN, UCSF Pediatric Dentistry gathers information on:

■ Medical history, including behavioral diagnosis.

■ Dental history, including oral hygiene practices.

■ Behavioral support services the child is receiving, such as applied behavior analysis (ABA), speech therapy, occupational therapy or physical therapy.

■ Education, including school level and type of classroom (integrated or special education).

■ Communication, including expressive language ability, receptive language ability, reading level and specific communication styles or tools used at home or school, if any, such as visual schedules, social stories, timers or picture exchange communication systems.

■ Sensitivities the child may have, especially in association with a dental setting, such as sensitivities to bright lights, sounds, tastes or smells.

An important part of this initial consultation is asking the parent how their child’s last dental visit went and how the parent feels the visit could have been improved. Additionally, this consultation gathers information on the best incentives and relaxing methods for the child. This initial telehealth consult allows the practitioner to gather information needed to see the patient, increases the practitioner’s preparedness for a successful dental visit and reduces the amount of time that the patient spends in the dental office.

Pre-visit imagery is an antecedent intervention that can be used prior to in-office desensitization.

Patients who are able to and want to meet with the dental team via telehealth prior to their first in-office dental visit are invited to join the telehealth visit. This provides the patient an opportunity to meet the dental team in a nonthreatening environment and become familiar with the providers prior to the actual appointment. This also enables patients to ask their own questions and express their concerns, thus allowing them to be an active participant in the conversation about their care.

Pre-Visit Imagery

Pre-visit imagery is an antecedent intervention that can be used prior to in-office desensitization. [24] It allows individuals to start to gain exposure to the dental setting and dental care without having to be physically present in the dental setting or to actually undergo a procedure. Pre-visit imagery can include pictures, social stories, videos and virtual dental office tours. UCSF Pediatric Dentistry has created a six-minute video that demonstrates a routine dental visit: the check-in process, the dental chair, personal protective equipment, a mouth mirror, an explorer, prophylaxis, an air/ water syringe, suction and the ending of the dental visit. Video modeling such as this has been shown to improve behavioral function for individuals with ASD. [25] The UCSF dentist sends this video to the patient’s parent/guardian, with the request that the child watch the video at least once before their first clinical visit. With the advent of free and accessible video production through cellphones and websites, individual dental offices can easily make and share pre-visit videos to prepare their patients for in-office dental visits.

Interprofessional Care With Behavioral Therapists

UCSF Pediatric Dentistry works with a board-certified behavior analyst (BCBA) to design, implement and support desensitization plans for children with SHCN. While dentists may not have a BCBA or other behavioral health professional on-site, dentists can work interprofessionally with their patients’ behavioral therapists. If a SHCN patient is known to receive ABA therapy or have an occupational therapist, the dentist can discuss aspects of the dental visit with the ABA or occupational therapist and request that they help to prepare the patient for their upcoming dental visit during their therapy sessions. Furthermore, dentists can work with patients’ ABA or occupational therapists to help set goals for improvement and implementation of home oral hygiene practices, such as brushing and flossing.

Systematic Desensitization

Following the initial telehealth consultation and pre-visit imagery, the patient presents to the dental clinic for their first desensitization visit. During the first dental visit, the goal is to determine the child’s comfort level and ability to complete a routine dental visit. Based on the individual’s behavioral needs during this first visit, the child may only enter the dental operatory or may complete the entire dental visit. The assessment of the patient’s comfort with and ability to complete a dental visit progresses from the patient’s ability to be in the dental chair to additional steps of a dental visit, such as examination, prophylaxis and completion of radiographs.

During dental desensitization visits, the child is gradually exposed to each step of the goal dental procedure. If the child can be in the dental room comfortably, they are asked or indicated to sit in the dental chair; if this is comfortable for the child, the next steps are introduced to the child progressively. If at any point the child begins to show signs of anxiety, such as covering their eyes, ears or nose, moving away from the stimulus, crying or trying to escape, the stimulus is removed and a calming stimulus is introduced.

Halting progress of the dental appointment and implementing behavioral supports at the initial signs of distress are more likely to allow the visit to continue successfully than waiting until the patient is highly distressed before pausing and addressing the behavioral need. The calming stimulus can be individualized for each child, but examples include watching videos on a tablet, playing with a fidget toy or listening to music. If the child appears to no longer be anxious, the last attempted step of the dental visit is reintroduced. The pattern of introducing a dental step, observing how the child responds and pairing a calming stimulus as needed is repeated. If the child cannot be calmed, the visit is terminated at that time. An appointment is then scheduled for the child in one to two months to reintroduce the anxiety-inducing step and attempt to progress through the remaining steps of the visit. Each patient has a different level of ability during the first visit, and goals are set for the next visit based on what has been accomplished thus far. Through repeated exposure to the dental setting and the steps leading up to a procedure, most children can learn tolerance and gain acceptance to complete an entire routine dental visit. [21]

Office Environment Accommodations for Desensitization Visits

Dental desensitization can happen in any dental office, however, making some accommodations to suit preferences and needs of patients can aid in the success of these visits. An initial accommodation made in the desensitization appointment is to eliminate or reduce time that the patient is in the waiting room or reception area. These settings can have many unfamiliar people, be highly active and be uncomfortable for individuals with ASD. At desensitization visits, the patient is greeted immediately in the waiting area and is not asked to sit in the waiting room. To further reduce distractions and overstimulation, desensitization visits are completed in dental operatories that are protected from the other clinical space, such as a “quiet room.”

Additional accommodations for these desensitization visits include providing supports that meet the preferences of the patient. Patients who have sensory differences are offered sunglasses to protect their eyes, noise cancelling headphones and weighted blankets. Options are also provided to meet patient preferences such as a variety of toothpaste flavors and manual or electric toothbrushes. Some patients also benefit from the use of calming sensory-related items/toys. For these patients at the desensitization visits, music may be played and a sensory toy box is offered with items such as fidget spinners, squishy balls and visually pleasing items like a liquid bubble timer. These items allow patients who prefer increased sensory stimulation to have an improved dental office experience. [26]

Home Oral Health Practice

Establishing a team with the parents and/or caregivers of children and adolescents with SHCNs is an essential element for successful desensitization in the dental environment. The parents and caregivers of these patients provide the majority of oral health care, and these home oral health practices are imperative in caries prevention. Furthermore, addressing caregiver burden and providing support to caregivers is important in improve the oral healthrelated quality of life for patients and their families. [27] The role of dental and behavioral providers is to advise and support the caregivers of patients. A team approach incorporating the dental and behavioral providers, caregivers and patient enables preventive oral health practices and dental desensitization to be practiced and maintained outside of the dental office environment. [28]

Some steps of a dental visit that pertain to a goal the provider has set can be practiced at home. If the child finds a mouth mirror to be anxiety inducing, the provider can send a plastic mirror home with the parent/guardian to practice using with the child prior to their next dental visit. If the provider plans to apply silver diamine fluoride at a future visit, they can provide the parent/guardian with a microbrush and cotton rolls to mimic the procedure with the child at home. Home practice can facilitate increased desensitization for the patient without having to be in the dental setting. [28] Dental providers can also work interprofessionally with a patient’s ABA therapist to describe specific goals of the next dental visit and encourage the patient to practice the corresponding steps outside of the dental setting.

Conclusion

The number of children referred for dental treatment using general anesthesia can be reduced using community-based strategies and interventions. These can result in a “warm handoff” of a behavior support plan and other information that can lead to treatment in that office rather than a subsequent referral for dental care using general anesthesia.

Even in locations where communitybased interventions are not available, important strategies can be adopted in dental office environments. Through repeated short desensitization visits and gradual acceptance of aspects of the dental visit, children and adolescents can gain the skills necessary to complete a dental visit without restraint, sedation or anesthesia. Pairing this with early preventive dental care and improved diet and home oral hygiene can greatly reduce dental disease in CSHCN and increase their ability to complete dental visits, ultimately reducing the number of children referred for dental care with general anesthesia for solely behavioral reasons.

ACKNOWLEDGMENTS:

The UCSF pediatric dentistry dental desensitization program is funded in part by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3.2 million with 0% percentage financed with nongovernmental sources. The contents are those of the authors and do not necessarily represent the official views of nor an endorsement by the HRSA, the HHS or the U.S. government.

REFERENCES

1. HRSA Maternal and Child Health. Improving the Lives of Children and Youth with Special Health Care Needs (CYSHCN). Accessed Nov. 28, 2021.

2. Glassman P, Subar P. Improving and maintaining oral health for people with special needs. Dent Clin North Am 2008 Apr;52(2):447–61, viii. doi: 10.1016/j.cden.2007.11.002.

3. Council AO. Guideline on management of dental patients with special health care needs. Pediatr Dent Sep–Oct 2012;34(5):160–5.

4. Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children’s Health. As cited in Children with special health care needs: A profile of key issues in California. Lucile Packard Foundation for Children’s Health: Oct. 2010.

5. Van Dyck PC, Kogan MD, McPherson MG, Weissman GR, Newacheck PW. Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med 2004 Sep;158(9):884–90. doi: 10.1001/archpedi.158.9.884.

6. Guideline on caries-risk assessment and management for infants, children and adolescents. Pediatr Dent Sep–Oct 2013;35(5):E157–64. 7. Lebrun-Harris LA, Canto MT, Vodicka P, Mann MY, Kinsman SB. Oral health among children and youth with special health care needs. Pediatrics 2021 Aug;148(2):e2020025700. doi: 10.1542/peds.2020-025700. Epub 2021 Jul 21.

8. Craig MH, Scott JM, Slayton RL, Walker AL, Chi DL. Preventive dental care use for children with special health care needs in Washington’s Access to Baby and Child Dentistry program. J Am Dent Assoc 2019 Jan;150(1):42–48. doi: 10.1016/j.adaj.2018.08.026. Epub 2018 Oct 24.

9. Rudie MN, Milano MM, Roberts, MW, Divaris K. Trends and characteristics of pediatric dentistry patients treated under general anesthesia. J Clin Pediatr Dent 2018;42(4):303–306. doi: 10.17796/1053-4628-42.4.12. Epub 2018 May 11.

10. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth 2013 Aug;23(8):741–6. doi: 10.1111/pan.12210. Epub 2013 Jun 14.

11. Kanellis MJ, Damiano PC, Momany ET. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia. J Public Health Dent Winter 2000;60(1):28–32.

12. Guidry J, Bagher S, Felemban O, Rich A, Loo C. Reasons of repeat dental treatment under general anaesthesia: A retrospective study. Eur J Paediatr Dent 2017 Dec;18(4):313– 318. doi: 10.23804/ejpd.2017.18.04.09.

13. Lewis CW, Nowak AJ. Stretching the safety net too far: Waiting times for dental treatment. Pediatr Dent Jan-Feb 2002;24(1):6–10.

14. Keels MA, Vo A, Casamassimo PS, Litch CS, Wright R, eds. Denial of Access to Operating Room Time in Hospitals for Pediatric Dental Care. Chicago: Pediatric Oral Health Research and Policy Center, American Academy of Pediatric Dentistry; April, 2021.

15. Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. Chicago: American Academy of Pediatric Dentistry; 2020:292–310.

16. Glassman P, Caputo A, Dougherty N, Lyons R, Messieha Z, Miller C, Peltier B, Romer M. Special Care Dentistry Association consensus statement on sedation, anesthesia and alternative techniques for people with special needs. Spec Care Dentist Jan–Feb 2009;29(1):2–8; quiz 67–8. doi: 10.1111/j.1754- 4505.2008.00055.x.

17. California Department of Developmental Disabilities. Regional Centers. Accessed Nov. 28, 2021.

18. California Northstate University College of Dental Medicine. The Virtual Dental Home System. Accessed Nov. 28, 2021.

19. California Northstate University College of Dental Medicine. The California Dental Transformation Initiative Local Dental Pilot Projects. Accessed Nov. 28, 2021.

20. Koegel RL, Openden D, Koegel LK. A systematic desensitization paradigm to treat hypersensitivity to auditory stimuli in children with autism in family contexts. Res Pract Persons Severe Disabil 29(2):122–134. doi.org/10.2511/ rpsd.29.2.122.

21. Nelson, T, Chim, A, Sheller, BL, McKinney CM, Scott JM. Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program. J Am Dent Assoc 2017 Jul;148(7):485–492. doi: 10.1016/j.adaj.2017.03.015. Epub 2017 Apr 19.

22. Yost Q, Nelson T, Sheller B, McKinney CM, Tressel W, Chim AN. Children with autism spectrum disorder can maintain dental skills: A two-year case review of desensitization treatment. Pediatr Dent 2019 Sep 15;41(5):397–403.

23. Cady R, Kelly A, Finkelstein S. Home telehealth for children with special health-care needs. J Telemed Telecare 2008;14(4):173–7. doi: 10.1258/jtt.2008.008042.

24. Fauziah E, Rachmawati S, Rachmadani AP, Susilo CW. Comparison of the educational effect of two and three dimensional books on dental anxiety in children with hearing impairment (aged 7–9 years). Indian J Public Health Res Dev 10(7):543. doi:10.5958/0976-5506.2019.01627.9.

25. Bellini S, Akullian J. A meta-analysis of video modeling and video self-modeling interventions for children and adolescents with autism spectrum disorders. Except Child 73(3):264–287. doi.org/10.1177/001440290707300301.

26. Kuhaneck HM, Chisholm EC. Improving dental visits for individuals with autism spectrum disorders through an understanding of sensory processing. Spec Care Dentist Nov–Dec 2012;32(6):229–33. doi: 10.1111/j.1754- 4505.2012.00283.x.

27. Petrova EG, Hyman M, Estrella MRP, Inglehart MR. Children with special health care needs: Exploring the relationships between patients’ level of functioning, their oral health and caregivers’ oral health-related responses. Pediatr Dent May–Jun 2014;36(3):233–9.

28. Ferguson FS, Cinotti D. Home oral health practice: The foundation for desensitization and dental care for special needs. Dent Clin North Am 2009 Apr;53(2):375–87, xi. doi: 10.1016/j.cden.2008.12.009.

THE CORRESPONDING AUTHOR, Jean Calvo, DDS, MPH, can be reached at Jean.Calvo@ucsf.edu.