A similar percentage of participants in the healthy group and ASD group have visited dentists. Almost 2/3 of ASD participants and control subjects visited the dentist within the last year. This was comparable to findings reported in the UK16 and Saudi Arabia17 for dentist's visiting pattern by ASD children. However, the current findings do not agree with a previous study18 that revealed significant differences between the two groups of participants as healthy children significantly visited a dentist more than autistic children.
The findings of the current study reiterate on past literature with regard to the difficulty of ASD patients in accessing professional dental care, and locating dental practitioners willing or qualified enough to provide the necessary dental care to this group of individuals 19-21 . Majority of general practitioners reported previously their unwillingness to treat patients with autism 22 . In the current study, about 27% of dentists reported lack of adequate knowledge to manage autistic patients. This is consistent with a past parental survey in which dentist rejection to treat ASD patients was attributed to dental education where 58% of dentists reported inadequacy of their training to treat children with autism 20 . This explanation is supported by similar findings where specialized pediatric dentists were reported to treat more autistic individuals compared to general practitioners which can be related to receiving more specialized didactic and clinical training in the management of special need patients 22 . General practitioners have also expressed their willingness to treat individuals with autism provided they received more training in special oral health care needs 23 . The current study findings supported the notion that the shortage of specialized dentist like pediatric dentists was amongst the barrier to accessing proper oral health care. A significantly larger number of ASD participant cited this as a potential barrier compared to healthy control participants.
The common uncooperative behavior was also considered as one important reason for the unwillingness of dentists to treat ASD patients and presents an obstacle to access appropriate oral health care facilities 24 . Our study demonstrated that fear from dental treatment and feeling of embarrassment were amongst the significant barriers towards seeking dental care. This can be explained by the exaggerated sensory sensitivities of autistic patients, lack of psychological or emotional maturity, and their socially aversive nature. Furthermore, ASD participants reported that non-spacious dental office was deterrent to accommodating dental treatment. The uniqueness of autistic patients justifies adopting individualized measures to make dental office more comfortable environment to this group of special need population.
In the view of increasing access to oral care of autistic individuals, it is worth to utilize the least traumatic environment to accommodate the unique sensory and behavioral aberrations of this population. Multiple and simultaneous strategies, including visual, auditory, tactile and video goggles, are advocated to overcome difficulties in communication, social interactions, anxiety and sensory adaptation with dental office environment during providing dental care for ASD patients 25-27 . Adaptation strategies in dental environment proved efficacious in decreasing the negative reactions of ASD patients26 . These measures may reduce the need to resort to more advanced techniques of behavioral management like protective stabilization and general anesthesia.
Economic restrictions did not appear to pose a significant barrier to access dental treatment. Both groups reported their financial abilities to cover treatment costs. This is probably due to the fact that both groups did not differ significantly with regard to having insurance coverage. Needless to say that most children and especially children with special needs have medical insurance in Jordan. This also can partially explain the non-significant differences between autistic and healthy participants with regard to visiting a dentist.
The ASD participants’ caregivers perceived “dental office is too far away” and “inaccessible parking areas” as significantly important factors that may challenge their accessibility to dental care. These difficulties may be attributed to the awareness of ASD participants and their families to their pressing need for a specialized dentist who can provide professional special care, which may possibly involve increased travel time and other related difficulties 18 .
The above-discussed barriers to access to dental care patients especially ASD patients may raise the need to adopt measures that facilitate the access of this group of people to an appropriate oral health care facility. This enlightens the need to increase the number of specialized dentists in special need oral health to provide the needed professional dental treatment and education for autistic children. The increased awareness of ASD participants about the need for a qualified dentist is emphasized by the findings of the current study. Thus, more professional training is required for dentists at the predoctoral and postdoctoral level. Furthermore, dentists should be educated to introduce adaptation methods into their practice to meet the needs of this special need group of people. Special practical guidelines should be disseminated to further educate dentists working with autistic patients. ASD children and their families should also receive appropriate education in special need oral health care to be prepared for dental appointments.
Web-based networks dedicated to dental care of autistic children can be valuable in helping families locating the dental offices that provide qualified dental treatment to individuals with ASD. These networks can be informative and supportive to this special need population and increase the awareness and prepare ASD children to receive dental treatment more positively.
Several limitations in this should be noted. The current study investigated the ASD group was formed on the basis of registration in special care centers, so those who are not could not be investigated. In addition, this study is based on information collected by self-reported questionnaires, where it is difficult to confirm the trueness of the reported information from any other sources.