Challenges and solutions in managing dental problems in children with autism

Table 1 PICO framework for systematic search study

Questions	Population	Intervention	Comparison	Outcome
What are the most common dental problems in children with ASD?	Children with autism	Identifying most common dental problems in children with ASD	Typically developing children	Understanding autism-related dental problems
What are the main challenges in managing dental health in children with autism?	Children with autism	Identifying key barriers (behavioral, sensory, dietary, and communication challenges)	Typically developing children	Understanding autism-specific dental care needs
How effective are behavioral and sensory adaptation techniques in improving dental care compliance?	Children with autism	Use of desensitization techniques, visual aids, and social stories	Standard dental care approaches	Improved cooperation and reduced dental anxiety
Can oral probiotics help in reducing dental caries and periodontal disease in children with ASD?	Children with autism	Administration of dental probiotics	Standard fluoride and antimicrobial treatments	Reduced dental caries, improved oral microbiome balance
How can interdisciplinary collaboration improve dental care for children with autism?	Dentists, pediatricians, behavioral therapists	Integrated care approach	Standalone dental care	Enhanced dental outcomes and reduced stress for children
What role does parental education and involvement play in improving oral hygiene for children with ASD?	Parents of children with autism	Parent training programs on oral care	No structured parental guidance	Better at-home oral hygiene practices
How do modified dental tools and techniques (e.g., weighted blankets, noise-canceling headphones) improve dental experiences for children with ASD?	Children with autism	Use of specialized dental equipment and techniques	Conventional dental setting	Reduced sensory overload, improved compliance
Can digital tools (e.g., mobile apps, virtual reality) improve dental visits for children with autism?	Children with autism	Implementation of telehealth, VR simulations, and mobile applications	Traditional in-person consultations	Reduced dental anxiety and increased familiarity with dental procedures

ASD: Autism spectrum disorder; VR simulations: Virtual reality simulations.

Table 2 Summary of studies on the prevalence of dental disorders in children with autism spectrum disorder using the PICO framework

Ref.	Population	Intervention/Exposure	Comparison	Outcome	Study design	Key risk factors identified	Clinical implications	Study quality rating
Burgette and Rezaie[13], 2020	Children with ASD (n = 1228)	Caregiver-reported dental caries	Neurotypical children (n = 43927)	ASD children had 40% higher odds of developing dental caries (AOR = 1.4, 95%CI = 1.2–1.7)	Cross-sectional study using 2016 National Survey of Children's Health	Behavioral difficulties in oral hygiene; Dietary habits high in sugar; Limited access to specialized dental care	Need for early preventive measures, including caregiver education and fluoride use; Policy changes to improve insurance coverage for ASD dental care	High Quality
Azimi et al[15], 2022	Children with ASD and/or Intellectual Disability (ID)	Dental procedures under general anesthesia in hospitals	Neurotypical children	ASD/ID children had more extractions (68.7%) and fewer restorations (16.2%) Indigenous children had worse outcomes	Population-based cohort study (Western Australia)	Delayed diagnosis leading to severe decay; Sensory issues preventing routine care; Socioeconomic disparities (Indigenous children had worse outcomes)	Increase ASD-friendly preventive dental programs to avoid invasive treatments; Address racial and socioeconomic disparities in dental care	Moderate Quality
Babu and Roy[14], 2022	Children with ASD (n = 50)	Dental caries and salivary electrolyte analysis	Neurotypical children (n = 50)	ASD children had higher DMFT scores Altered salivary composition: Increased magnesium & decreased calcium, sodium, potassium.	Case-control study	Salivary imbalance may contribute to enamel erosion; Nutritional deficiencies (low calcium, sodium, and phosphorus)	Potential use of salivary biomarkers for early detection of caries risk; Saliva-enhancing therapies should be explored	High Quality
Azimi et al[16], 2022, WA study	Children with ASD and/or Intellectual Disability (ID)	Hospitalization for dental conditions	Neurotypical children	Higher hospitalization rates due to severe untreated dental disease Socioeconomically disadvantaged ASD children were at the highest risk	Retrospective cohort study (1983-2010)	Lack of preventive dental visits; Severe dental disease requiring extractions; Lower socioeconomic status	Mobile dental clinics & school-based interventions to improve access; Early screening programs in ASD children	Moderate quality
Lai et al[17], 2012	Children with ASD (n = 568)	Identifying barriers to dental care	General pediatric population	12% of ASD children had unmet dental needs Main barriers: Behavioral challenges, cost, and lack of insurance	Survey-based cross-sectional study	Caregiver’s own dental visit history influenced child’s access; Lack of ASD-trained dentists; Behavioral resistance to treatment	Expand insurance coverage for ASD-specific dental care - Train more dentists in ASD-friendly treatment approaches	Moderate Quality
de Souza et al[18], 2024	Children with ASD (n = 100)	Utilization of dental services	General pediatric population	25% had never been to a dentist Primary care engagement improved access	Cross-sectional study (Brazil)	Lack of awareness about the importance of dental care; Activity limitations due to ASD severity; Male caregivers were less likely to seek dental care for their children	Strengthen the role of primary care providers in promoting dental visits; Improve caregiver education and awareness	Moderate Quality

AOR: Adjusted odds ratio; ASD: Autism spectrum disorder; DMFT scores: Number of decayed (D), missing due to caries (M) and filled (F) teeth (T); ID: Intellectual disability.

Table 3 Summary of studies on challenges faced by children with autism spectrum disorder and their parents in dental care using the PICO framework

Ref.	Population	Intervention/Exposure	Comparison	Outcome	Study design	Key challenges identified	Clinical implications	Study quality rating
Alvares et al[20], 2023	Parents of children with ASD (n = 140)	Parental reports on oral health and barriers to care	None	26% of ASD children had untreated dental problems; 33% required general anesthesia for dental procedures	Cross-sectional study (Australian Autism Biobank)	Intellectual disability increased dental care challenges; sensory difficulties made access harder; functional limitations linked to greater dental problems	Need for personalized ASD-friendly dental care models; expand desensitization programs for children with ASD	Moderate quality
Alshihri et al[23], 2021	Parents of ASD children (n = 142)	Barriers to accessing professional dental care	None	68.3% of parents found it difficult to access dental care; 75.4% cited cost as a major barrier	Cross-sectional survey	Cost, lack of ASD-trained dentists, and child’s behavior were the main challenges; medical insurance and past dental experiences influenced access	Improve insurance coverage for ASD-specific dental care; increase training for dental professionals in ASD patient management	Moderate quality
Taneja and Litt[28], 2020	Parents of ASD children (n = 46)	Caregiver-reported barriers to dental care	Parents of neurotypical children with chronic illnesses (n = 37)	39% of ASD caregivers reported uncooperative child behavior as a key barrier	Case-control survey	Finding ASD-trained dentists was a major issue; parents of severe ASD cases reported the most difficulties	Promote ASD-specific behavior management training for dentists; develop caregiver education programs on oral hygiene techniques	Moderate quality
Barry et al[24], 2014	Parents of ASD children (n = 112)	Access and barriers to dental care	Parents of neurotypical children	ASD children had greater difficulties traveling to dental clinics; predicted more negative behaviors in dental settings	Case-control questionnaire	Difficulty accessing ASD-adapted dental clinics; travel to the dental office was harder for ASD children	Establish mobile dental services and home-based preventive care	Moderate quality
Azevedo Machado et al[29], 2022	Parents of ASD children and adolescents (n = 1001)	Impact of COVID-19 on dental care	None	61.6% of parents reported significant routine disruption; 59.3% believed their child feared PPE use	Cross-sectional online survey (Brazil)	Fear of PPE and changes in routine disrupted care; dental visits decreased during the pandemic	Develop tele-dentistry models for ASD children; train dentists to use ASD-friendly PPE and gradual exposure techniques	Moderate quality
Logrieco et al[27], 2021	Parents of ASD children (n = 57) & dentists (n = 61)	Experiences of ASD children, parents, and dentists during dental visits	Parents of neurotypical children (n = 275)	ASD children had higher dental anxiety; dentists found it difficult to manage ASD behaviors	Comparative study (Italy)	Lack of ASD-trained dentists was a major concern; caregivers struggled to find professionals	Increase dental training programs in ASD care; improve dentist-parent communication on behavior strategies	Moderate quality
Baek et al[22], 2024	ASD children (n = 209780)	Frequency and cost of dental visits	Neurotypical children	ASD children had fewer visits but higher costs; ASD children had higher rates of dental trauma	Population-based cross-sectional study (Korea)	Financial burden was higher for ASD families; trauma rates were significantly elevated	Improve affordable access to ASD-friendly dental services; increase preventive dental trauma education	High quality
Marshall et al[19], 2007	ASD children (n = 108)	Factors influencing cooperation in dental settings	None	65% of ASD children were uncooperative; language, sensory issues, and routine disruption affected cooperation	Survey-based study	Nonverbal children were less likely to cooperate; poor sensory adaptation increased uncooperative behavior	Implement structured pre-visit sensory adaptation; use individualized behavior management techniques	Moderate quality
McKinney et al[30], 2014	ASD children (n = 2772)	Predictors of unmet dental needs	None	15.1% of ASD children had unmet dental needs; lack of a medical home increased risk (AOR = 4.46)	National survey analysis (US)	Children with ASD and intellectual disability had worse access; lack of a primary healthcare connection increased risk	Integrate dental screenings into pediatric medical visits; improve referral pathways between doctors and dentists	High quality
Brickhouse et al[26], 2009	Parents of ASD children (n = unknown)	Barriers to dental care in Virginia	None	Difficult behavior and lack of ASD-trained dentists were the biggest barriers	Survey-based study	ASD children visited the dentist less frequently; difficulty finding willing and trained providers	Develop ASD training for general dentists; improve dental accessibility through policy reforms	Moderate quality
Loo et al[21], 2009	ASD children (n = 395)	Behavioral management in dental care	Neurotypical children (n = 386)	ASD children were more uncooperative; severe ASD cases required general anesthesia more often	Retrospective chart review	ASD patients with higher caries severity and sensory issues were harder to manage	Train dentists in non-pharmacological behavioral guidance techniques	Moderate quality
Wiener et al[25], 2016	Parents of ASD children (n = 16323)	Caregiver burdens and dental care access	None	16.3% of ASD children had unmet preventive dental needs; financial and employment burdens increased risks	National survey analysis	Financial and time constraints prevented access to preventive care	Improve dental insurance coverage and flexible scheduling for ASD families	High quality

ASD: Autism spectrum disorder; COVID-19: Coronavirus disease 2019; PPE: Personal protective equipment; US: United States.

Table 4 Summary of studies on modified dental tools and techniques for managing dental disorders in children with autism spectrum disorder using the PICO framework

Ref.	Population	Intervention	Comparison	Outcome	Study design	Key findings	Study quality rating
Dangulavanich et al[31], 2017	Children with ASD (n = 95)	Evaluated cooperation during dental treatment based on sensory processing factors and behavioral characteristics	None	Age, education, behavior before treatment significantly influenced cooperation	Cross-sectional study	Older children (11–18 years) and those in special education showed better cooperation	Moderate quality
Narzisi et al[32], 2020	Children with ASD (n = 59)	ICT-based intervention (MyDentist) to familiarize children with dental settings	Conventional dental visits	Improved oral hygiene and cooperation during treatment	Feasibility study	ICT interventions can enhance dental care acceptance without pharmacological interventions	Moderate quality
Octavia et al[33], 2025	Children with ASD (n = 37)	Structured-visual behavioral model for compliance and cooperation	Standard dental approach	Improved cooperation and compliance during dental exams	Quasi-experimental study	75% achieved the highest cooperation scores on the Frankl Behavior Scale (FBS)	Moderate quality
Mah and Tsang[34], 2016	Children with ASD (n = 14)	Visual schedule system for dental visits	Tell-show-do method	Faster task completion and lower behavioral distress	RCT	Visual schedules improved dental visit success rates	High quality
Isong et al[35], 2014	Children with ASD (n = 80)	Electronic screen media to reduce dental anxiety	No media intervention	Decreased anxiety and improved behavior during dental visits	RCT	Video peer modeling and video goggles reduced fear and increased cooperation	High quality
Cenzon et al[36], 2022	Dental hygiene students	SVT for ASD patient management	No SVT training	Improved confidence and knowledge in treating ASD patients	Pilot study	Virtual training enhances ASD dental care preparedness	Moderate quality
Thomas et al[37], 2018	Parents of children with ASD (n = 17)	Parental experiences with dental care access and needs	None	Identified need for flexible dental environments and better communication	Qualitative study	Family-centered care and dentist-parent communication are crucial	Moderate quality
Wibisono et al[38], 2016	Children with ASD & caretakers	Use of dental visit pictures as communication tools	None	Positive perception of visual aids for dental preparation	Qualitative study	Pictures enhanced understanding of dental visits among ASD children	Moderate quality
Cagetti et al[39], 2015	Children with ASD (n = 83)	Visual supports-based dental care protocol	Standard dental care	Increased acceptance of dental procedures	Observational study	Non-verbal children benefitted from visual training	Moderate quality
Naidoo and Singh[40], 2020	Children with ASD	Dental communication board for improved communication	No communication board	Enhanced interaction between children and dentists	Mixed-methods study	Visual communication tools facilitated dental visits	Moderate quality
Nilchian et al[41], 2017	Children with ASD (n = 6-12 years)	Visual pedagogy for dental check-ups	Standard approach	Increased compliance with dental check-ups	RCT	Visual pedagogy improved cooperation in dental visits	High quality

ASD: Autism spectrum disorder; ICT: Information and communication technologies; RCT: Randomized controlled trial; SVT: Simulated-virtual training.

Table 5 Summary of studies on behavioral and sensory adaptation techniques for managing dental disorders in children with autism spectrum disorder using the PICO framework

Ref.	Population	Intervention	Comparison	Outcome	Study design	Key findings	Study quality rating
Marion et al[42], 2016	Children with ASD (n = 40)	Use of dental stories to prepare for dental visits	No preparatory aids	64% of caregivers found dental stories useful for their child’s preparation	Survey-based study	Caregivers preferred individualized story formats to match child’s comprehension level	High quality
Star et al[43], 2023	Children with ASD (n = 52)	Dental desensitization program (task analysis approach)	Standard preventive visits	Increased comfort and step completion in dental visits	Prospective cohort study	Children with expressive and receptive language skills benefited most	Moderate quality
Cai et al[44], 2022	Parents of children with ASD (n = 13)	Parent-reported effectiveness of desensitization	No structured desensitization	Reduced anxiety and improved treatment acceptance	Qualitative study	Barriers include financial burden and frequent appointments	Low quality
Yost et al[45], 2019	Children with ASD (n = 138)	Two-year follow-up on desensitization treatment	Initial exam acceptance only	92% retained examination skills, 83% accepted toothbrush prophylaxis	Retrospective case series	Sensory-invasive skills (radiographs) were acquired less frequently	Moderate quality
Myhren et al[46], 2023	Children with ASD (n = 17)	Individualized dental habituation program	Standard dental exams	82% completed dental exams, increased compliance with mirror and probe	Mixed-methods study	Collaboration with school personnel improved outcomes	Moderate quality
Junnarkar et al[47], 2022	Occupational & speech therapists	Role of therapists in dental care	No therapist involvement	Identified barriers to oral care and potential solutions	Qualitative study	Therapists play a key role in early intervention and pre-visit preparation	Moderate quality
Luscre and Center[48], 1996	Children with ASD (n = 3)	Desensitization with anxiety-reducing stimuli	No desensitization	Increased step completion in a clinical setting	Experimental study	Systematic desensitization reduces dental fear	Moderate quality
Mah and Tsang[34], 2016	Children with ASD (n = 14)	Visual schedule system during dental visits	Tell-show-do method	Faster task completion, reduced distress	RCT	Visual schedules enhanced cooperation and reduced anxiety	High quality
Hernandez and Ikkanda[49], 2011	Children with ASD	ABA in dental care	Standard behavior management	Improved cooperation with dental procedures	Literature review	ABA principles effectively modify problematic dental behaviors	Low quality
Uliana et al[42], 2024	Children with ASD (n = 61)	Impact of behavioral factors on caries prevalence	Cooperative children	Higher support needs linked to increased caries rates	Cross-sectional study	Poor mealtime behavior and dental noncompliance increased caries risk	Low quality

ABA Applied behavior analysis; ASD: Autism spectrum disorder; RCT: Randomized controlled trial.

Table 6 Summary of studies on digital app use for improving dental and oral health in children with autism

Ref.	Population	Intervention	Comparison	Outcome	Study design	Key findings	Study quality rating
Tan et al[52], 2024	Caregivers and autistic children	Development of a mobile app with social stories, visual schedules, and communication tools for caregivers and dentists	No mobile app intervention	App was well-received by experts and parents; improved awareness and access to oral health resources	Developmental study	Highlighted the need for digital tools to support caregivers in managing oral health of autistic children	Moderate quality
Krishnan et al[53], 2021	Adolescents with ASD (13-17 years)	Mobile app (Brush Up) vs visual pedagogy for oral health education	No digital intervention	Significant reduction in plaque and gingival scores in both intervention groups	Interventional parallel-arm study	Mobile apps and visual pedagogy were equally effective in improving oral hygiene in autistic adolescents	High quality
Lefer et al[54], 2018	Children with ASD (3-19 years)	Tablet-based training program using pictograms (çATED app) for tooth brushing	Traditional instruction	Improved brushing skills and autonomy in children using the app	Exploratory study	Demonstrated effectiveness of digital tools in teaching oral hygiene habits	High quality
Stamatović et al[55], 2023	Children with ASD and their families	Mobile app in Serbian for dentist visit support	No app intervention	App improved cooperation with dentists and reduced anxiety	Cross-sectional study	Suggested mobile apps can help autistic children adapt to dental visits	Moderate quality

ASD: Autism spectrum disorder; çATED: Digital agenda designed for individuals with autism (name of the application).

Table 7 Summary of studies on parental and healthcare professional education on managing dental disorders in children with autism using the PICO framework

Ref.	Population	Intervention	Comparison	Outcome	Study design	Key findings	Study quality rating
Parry et al[59], 2021	Parents of autistic children	Partnership Working, System Change, and Training of Dental Staff	No structured intervention	Improved parent confidence and advocacy in dental settings	Qualitative Focus Group Study	Highlighted the need for tailored interventions and better understanding of sensory and communication barriers	Low quality
Chanin et al[60], 2023	Parents of autistic children (n = 235)	Parent perception assessment of child’s behavior during first dental visit	No structured parental feedback system	Age and ethnicity influenced dental visit success; parental perception significantly predicted behavior	Cross-sectional study	Demonstrated that coordinating with parents improved dental visit outcomes	Moderate quality
Fenning et al[57], 2022	Underserved autistic children (n = 119)	Parent Training for oral hygiene improvement	Psychoeducational dental toolkit	Increased twice-daily toothbrushing (78% vs 55% at 3 months); reduced plaque and caries development	RCT	Parent Training significantly improved oral hygiene, reducing problem behaviors and dental caries	High quality
Du et al[58], 2019	Preschool children with ASD and their parents (n = 257)	Assessment of oral health behaviors and barriers	Age- and gender-matched neurotypical children	ASD children brushed less frequently and required more parental assistance; parents had higher dental knowledge	Cross-sectional study	Highlighted need for specialized parental education programs	Moderate quality
Lewis et al[61], 2015	Parents of autistic children (Focus Groups)	Parental perspectives on dental care experiences	No structured support system	Need for individualized care approaches and increased parental involvement	Qualitative study	Identified variability in ASD children's dental care tolerance and emphasized family-centered approaches	Low quality
Polprapreut et al[62], 2022	Children with developmental disabilities (n = 263)	Analysis of parenting styles and unmet dental needs	Positive vs less positive parenting styles	Less positive parenting styles were linked to higher unmet dental needs (OR = 2.19)	Cross-sectional study	Highlighted role of parenting styles in dental health outcomes	High quality
Manopetchkasem et al[64], 2023	Parents of autistic children (n = 141)	Parental acceptance of Advanced BGTs	Parents with vs without prior BGT experience	Parents with experience rated BGTs more favorably	Cross-sectional study	Prior exposure to BGTs increased acceptance and reduced resistance	Moderate quality
Tahririan et al[56], 2021	Parents of autistic children (n = 100)	Knowledge, attitude, and performance regarding hospital dentistry	No structured education on hospital dental services	56% had poor knowledge; 69% reported low child cooperation	Cross-sectional study	Identified gaps in parental knowledge about hospital dental care	Moderate quality
Junnarkar et al[65], 2023	Parents of autistic children (n = 23)	Barriers and coping strategies in accessing dental care	No structured parental education program	Identified sensory issues, financial constraints, and lack of specialized dentists as main barriers	Qualitative study	Recommended improving parental awareness and financial support for multiple acclimatization visits	Low quality
Verma et al[63], 2022	Parents of autistic children	Assessment of unmet dental needs and barriers	No targeted intervention	Identified socio-psychological factors influencing dental care utilization	Cross-sectional study	Found financial and psychological barriers were key obstacles to dental care	Moderate quality
Marshall et al[66], 2008	Healthcare professionals treating autistic children	Evaluation of BGTs used in dental treatment	No structured training on BGTs	Parents accurately predicted child cooperation; positive reinforcement and tell-show-do were most accepted	Survey-based study	Basic BGTs were more accepted than advanced techniques; parental attitudes influenced acceptance	Moderate quality

ASD: Autism spectrum disorder; BGTs: Behavior guidance techniques; OR: Odds ratio; RCT: Randomized controlled trial.

Table 8 Summary of studies on oral microbiota in children with autism

Ref.	Population	Intervention	Comparison	Outcome	Study design	Key findings	Study quality rating
Kong et al[70], 2019	Children with ASD and neurotypical controls	Analysis of oral and gut microbiota using 16S rRNA sequencing	Neurotypical children	Identified distinct oral and gut microbiota signatures; explored microbial biomarkers for ASD diagnosis	Pilot study	ASD children had unique oral microbiota profiles with potential diagnostic biomarkers; suggested probiotics could alter microbiome and improve comorbid conditions	Moderate quality
Evenepoel et al[71], 2024	80 autistic children (8-12 years) and 40 neurotypical peers	Examination of oral microbiota differences using high-throughput sequencing	Typically developing children	ASD children had higher abundances of Solobacterium, Stomatobaculum, Ruminococcaceae UCG.014, Tannerella, and Campylobacter; associations found with social difficulties and anxiety	Cross-sectional study	Oral microbiome variations correlated with ASD symptom severity and were not significantly driven by lifestyle factors	High quality
Qiao et al[72], 2018	32 ASD children and 27 healthy controls	High-throughput sequencing of salivary and dental microbiota	Neurotypical children	ASD children had lower bacterial diversity, higher pathogenic bacteria (Haemophilus, Streptococcus), and reduced commensals (Prevotella, Fusobacterium, Actinomyces)	Case-control study	Significant microbiota differences in ASD children; proposed microbial markers for ASD diagnosis	Moderate

ASD: Autism spectrum disorder; rRNA: Ribosomal ribonucleic acid.

Table 9 The compounding factors impacting oral health in children with autism spectrum disorder

Factor	Impact on oral health
Sensory aversions	Resistance to brushing/flossing due to texture/taste sensitivities
Dietary preferences	High sugar/carbohydrate intake (soft/sticky foods) promotes decay
Medication side effects	Dry mouth (xerostomia) reduces saliva’s protective role, increasing cavity risk
Behavioral challenges	Self-injurious behaviors (e.g., cheek biting) or bruxism cause physical damage to teeth and soft tissues
Communication barriers	Delayed diagnosis due to inability to express pain/discomfort

Table 10 Differences in prevalence and types of dental issues between children with autism spectrum disorder and neurotypical peers

Dental issue	Children with ASD	Neurotypical children
Caries (Cavities)	Varies; some studies report lower rates (due to diet and assistance with oral hygiene), while others indicate higher rates (due to difficulty in brushing and dietary preferences)	Generally moderate to high prevalence, influenced by diet and hygiene habits
Gingivitis	Higher prevalence due to oral hygiene challenges and sensory sensitivities that make brushing and flossing difficult	Lower prevalence with proper hygiene habits
Periodontal disease	Increased risk due to poor oral hygiene, limited dental visits, and difficulty tolerating dental care	Less common but can occur with inadequate hygiene
Malocclusion (Misalignment of Teeth)	More frequent, often associated with oral habits like bruxism, tongue thrusting, and prolonged pacifier use	Less frequent but can occur due to genetic or environmental factors
Bruxism (Teeth Grinding)	High prevalence; often linked to anxiety, sensory processing issues, or self-stimulatory behaviors	Less common; usually stress-related
Dental trauma	Higher prevalence due to self-injurious behaviors, seizures, or lack of motor coordination	Occurs mainly due to accidents during play or sports
Drooling and hypersalivation	More common, associated with low muscle tone and neurological differences	Less common, usually seen in younger children
Hypoplasia (Enamel Defects)	Increased prevalence; may be linked to genetic factors, medication use, or nutritional deficiencies	Less frequent but can still occur
Tooth extraction needs	Higher due to untreated dental issues, poor cooperation during treatment, and difficulty accessing dental care	Lower, as routine dental visits and interventions prevent extractions
Dental visit challenges	Anxiety, sensory sensitivities, difficulty with cooperation, and communication barriers lead to fewer and less successful visits	Generally cooperative with routine dental care, with fewer barriers

ASD: Autism spectrum disorder.

Table 11 The developmental teeth disorders in children with autism spectrum disorders

Developmental teeth disorder	Description	Causes	Prevalence in ASD	Consequences
Enamel hypoplasia	Thin, pitted, or discolored enamel due to defective enamel formation	Genetic mutations (e.g., AMELX, ENAM), prenatal stressors (maternal infections, nutritional deficiencies), postnatal nutrient deficits (low calcium/vitamin D)	Higher prevalence compared to neurotypical peers	Increased cavities, tooth sensitivity, rapid decay
Delayed tooth eruption	Primary/permanent teeth emerge later than typical timelines	Systemic developmental delays, endocrine imbalances (e.g., hypothyroidism), nutritional deficiencies from selective eating	More common in ASD, especially with comorbid growth/hormonal disorders	Misalignment, crowding, chewing/speech difficulties
Malocclusion	Misaligned teeth or jaws (e.g., overbite, crowding)	Oral motor dysfunction (hypotonia), persistent habits (thumb-sucking, pacifier use), bruxism (teeth grinding)	Higher rates reported in ASD	Difficulty chewing, speech impediments, increased risk of dental trauma
Supernumerary/Missing teeth	Extra teeth (supernumerary) or congenital absence of teeth (hypodontia)	Genetic syndromes overlapping with ASD (e.g., Smith-Magenis syndrome)	Occurs more frequently in syndromic ASD cases	Crowding, impaction, functional gaps requiring prosthetics
Taurodontism	Molars with enlarged pulp chambers and shortened roots ("bull-like" teeth)	Associated with neurodevelopmental disorders; exact cause unclear	Observed more frequently in ASD	Structural weakness, increased fracture risk, challenges during root canals

ASD: Autism spectrum disorder.

Table 12 Medical comorbidities and associated dental disorders in children with autism spectrum disorder

Medical comorbidity	Associated dental disorder(s)	Impact on oral health
Gastrointestinal Issues (e.g., acid reflux, vomiting)	Enamel erosion, tooth sensitivity, increased risk of decay	Exposure to stomach acids leads to weakened enamel and increased vulnerability to cavities
Epilepsy (and anticonvulsant medications)	Gingival hyperplasia (gum overgrowth), periodontal disease	Plaque buildup in gum pockets due to overgrowth increases the risk of periodontal problems
Genetic syndromes (e.g., Fragile X, Down syndrome)	Enamel defects, delayed eruption, malocclusion	Inherent dental anomalies complicate oral health and require specialized dental care
Sleep disorders (e.g., disrupted sleep patterns)	Bruxism (teeth grinding), enamel wear, jaw pain, tooth fractures	Grinding leads to accelerated wear on teeth, causing damage and sensitivity
Immune dysregulation/chronic inflammation	Gingivitis, periodontitis	Reduced ability to combat oral pathogens, leading to infections and gum disease
Nutritional deficiencies (e.g., calcium, vitamin D)	Weakened enamel, reduced saliva production	Deficiencies compromise enamel development and the mouth's natural defense against cavities
Psychotropic medications (e.g., antipsychotics)	Xerostomia (dry mouth), bacterial overgrowth, halitosis, rampant caries	Dry mouth fosters bacterial growth, increasing risk of tooth decay and gum disease
Metabolic disorders (e.g., mitochondrial dysfunction)	Delayed healing of oral injuries, infections	Impaired tissue repair, leading to prolonged healing times for oral wounds or infections
Dental issues common in ASD	Dental caries, acid erosion, gingivitis, periodontal disease, malocclusion, bruxism, non-nutritive oral habits	Poor oral hygiene, sugary diets, medication side effects, and sensory sensitivities elevate the risk of these issues

ASD: Autism spectrum disorder.

Table 13 Role of oral (Dental) probiotics in managing dental problems in children with autism spectrum disorder

Dental issue	Challenges in children with ASD	Role of oral probiotics	Common probiotic strains
Dental caries (Cavities)	Preference for sugary, soft foods; difficulty in oral hygiene	Inhibits S. mutans, lowers oral pH, produces antimicrobial compounds	Lactobacillus reuteri, Lactobacillus paracasei, Lactobacillus rhamnosus
Periodontal disease (Gingivitis & Periodontitis)	Poor brushing & flossing; plaque buildup	Reduces inflammation, inhibits P. gingivalis, decreases pro-inflammatory cytokines	L. reuteri, Streptococcus salivarius
Halitosis (Bad Breath)	Poor oral hygiene, medication-induced dry mouth	Reduces odor-producing bacteria, neutralizes volatile sulfur compounds	S. salivarius K12, L. reuteri
Enamel erosion	GERD, acidic dietary habits	Increases saliva production, enhances buffering capacity of saliva	L. reuteri, Bifidobacterium spp.
Xerostomia (Dry Mouth)	Medication side effects reducing saliva production	Stimulates saliva flow, maintains oral moisture	L. reuteri, S. salivarius
Oral candidiasis (Thrush)	Immune dysregulation, prolonged antibiotic use	Inhibits Candida albicans overgrowth, supports oral microbiome balance	L. reuteri, Bifidobacterium spp.
Bruxism (Teeth Grinding)	Sensory sensitivities, stress, sleep disturbances	Promotes oral tissue repair, reduces inflammation in gum tissues	L. reuteri, L. paracasei

ASD: Autism spectrum disorder; L. reuteri: Lactobacillus reuteri; L. paracasei: Lactobacillus paracasei; P. gingivalis: Porphyromonas gingivalis; S. mutans: Streptococcus mutans; S. salivarius: Streptococcus salivarius; GERD: Gastroesophageal reflux disease.

Table 14 Commonly used probiotics for dental caries prevention and treatment

Probiotic strain	Mechanism of action	Potential benefits in dental health
Lactobacillus reuteri	Inhibits S. mutans and P. gingivalis growth, reduces inflammation	Reduces dental caries and gum disease[142]
Streptococcus salivarius K12	Produces bacteriocins that inhibit odor-causing bacteria	Reduces halitosis and enhances oral immunity[144]
Lactobacillus paracasei	Competes with S. mutans for adhesion sites, modulates pH	Lowers risk of cavities and enamel demineralization[143]
Lactobacillus rhamnosus	Enhances salivary immunity and prevents biofilm formation	Supports gum health and reduces plaque[141]
Bifidobacterium species	Suppresses Candida albicans growth and promotes beneficial microbiota	Prevents oral thrush and fungal infections[147]

P. gingivalis: Porphyromonas gingivalis; S. mutans: Streptococcus mutans.

Table 15 Recommendations for improving dental care in children with autism spectrum disorder

Target audience	Key recommendations	Expected benefits
Caregivers	Implement structured oral hygiene routines using visual schedules, sensory-friendly toothbrushes, and non-foaming toothpaste	Improves cooperation, reduces sensory aversions, and establishes consistent oral care habits
	Use positive reinforcement strategies (e.g., rewards, social stories, or gamification) to encourage daily brushing and flossing	Enhances motivation and engagement in oral hygiene
	Seek ASD-trained dental professionals and schedule pre-visit desensitization sessions	Reduces dental anxiety and improves cooperation during clinical visits
	Encourage a balanced diet with limited sugary or acidic foods and promote water intake for oral health	Reduces risk of cavities and acid erosion
	Consider probiotic supplements (if recommended) to support oral microbiota and prevent dental caries	Enhances oral microbial balance and reduces inflammation
Dentists & dental professionals	Adapt the dental environment (dim lights, noise reduction, weighted blankets, sensory-friendly tools)	Minimizes sensory overload and improves patient comfort
	Use visual communication aids (picture schedules, social stories, and modeling videos)	Enhances understanding and predictability for ASD patients
	Implement gradual desensitization protocols and behavioral techniques (Tell-Show-Do method, distraction strategies)	Increases patient cooperation and reduces dental fear
	Provide ASD-specific training for dental staff to enhance communication and behavioral management skills	Improves patient-dentist interaction and treatment success
	Offer shorter, flexible, or split appointments based on patient needs	Reduces stress and increases the likelihood of completing treatment
	Use alternative sedation techniques (if necessary), ensuring safe administration for children with severe anxiety or sensory issues	Enhances safety while ensuring comprehensive treatment completion
Policymakers & healthcare administrators	Increase access to ASD-specialized dental training in dental schools and continuing education programs	Expands the workforce of ASD-trained dental professionals
	Implement insurance policies that cover ASD-specific dental care (e.g., behavioral adaptations, extended visits, sedation if necessary)	Reduces financial barriers to receiving specialized dental care
	Promote interdisciplinary collaboration between pediatricians, occupational therapists, behavioral specialists, and dentists	Creates a holistic approach to ASD dental care and improves patient outcomes
	Support the development of digital applications and tele-dentistry solutions to assist ASD families with home-based oral care	Increases accessibility to oral health education and remote guidance
	Encourage funding for research on ASD dental care interventions, including behavioral adaptations, probiotics, and technology-driven solutions	Drives innovation in evidence-based ASD-specific dental practices

ASD: Autism spectrum disorder.