The pathophysiology, medical management, and dental implications of children and young adults having attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder is considered to be the most common neurobehavioral disorder among school-aged children. Children who have ADHD exhibit symptoms of inattention, hyperactivity, and impulsivity that are extreme for their age. These symptoms adversely affect academic performance, vocational success, and social-emotional development. The disorder is usually treated with stimulant medications, but on occasion antidepressants and certain antihypertensive agents are used. Dentists caring for individuals with ADHD must be familiar with the manifestations of the disease and its associated features so they can garner the maximum level of cooperation from the patient. They must also be familiar with the drugs used to treat the disorder because many of these pharmaceuticals cause adverse orofacial and systemic reactions and may interact with dental therapeutic agents.     

Traumatic dental injuries and attention‐deficit/hyperactivity disorder: is there a link?

Abstract –  Traumatic dental injuries (TDIs) constitute a major cause of morbidity among children worldwide. Both TDIs and attention-deficit/hyperactivity disorder (ADHD) are prevalent conditions with similar male-to-female predominance and similar age of presentation. While the commonest causes of TDIs have been identified as playground or sports accidents, a well-known feature of ADHD is accident proneness. Violence, another significant risk factor for TDIs, is more likely to be observed in conduct disorder, a common comorbidity of ADHD. Also, both TDIs and ADHD have been found to be associated with left-handedness. The presence of multiple dental trauma episodes (MDTE), as well as increased risk for non-dental injuries in children with TDIs indicates an underlying persistent condition, which resembles ADHD. Higher point prevalence of mental distress at age 30, found to be associated with increased lifetime prevalence of TDIs, may also be taken as an evidence of a background developmental disorder persisting into adulthood with various comorbidities. In conclusion, this review combines the results of several studies and explains the significance of ADHD as an underlying and predisposing factor for TDIs. Increased awareness and close collaboration between different disciplines involved are essential.     

Relationship between traumatic dental injuries and attention-deficit/hyperactivity disorder in children and adolescents: proposal of an explanatory model

Abstract –  The objective of the present study was to determine the association between attention-deficit/hyperactivity disorder (ADHD) and traumatic dental injuries in a child psychiatric clinical population in Istanbul. A total of 475 consecutive children aged 8–17 years were enrolled in the study. Children and their parents were interviewed about the presence of traumatic dental injury and if a positive response was obtained further questions were inquired regarding the time and cause of the injury, and whether treatment had been sought. Child psychiatric diagnosis was based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. Of the 475 children, 32 reported a traumatic dental injury (6.7%) with statistically significant association with ADHD ( χ ² = 26.90, d.f. = 1, P  = 0.0001; odds ratio = 17.41, 95% CI: 4.11–73.55). On the Conners Teacher Report Questionnaire, children with dental trauma group differed significantly from the non-ADHD group but not from the ADHD group ( F  = 17.02, d.f. = 2, P  = 0.0001). Among children with ADHD and dental fracture, the most common subtype was combined ADHD (90%). This is the first study describing a significant association between dental fractures and ADHD which contributes to an explanatory model on dental traumas among children. According to us, awareness of this association is essential at child psychiatry and pediatric dentistry settings and we recommend preventive efforts to be directed at the treatment of ADHD.     

Tips for managing children with attention deficit hyperactivity disorder in the dental setting

It has been estimated that between 3% and 7% of children suffer from attention deficit hyperactivity disorder (ADHD). It is probable, therefore, that these children will present in any dental office. ADHD is characterized by inattention, overactivity and impulsivity. Such symptoms can be quite severe and often present challenges in the dental setting. ADHD symptoms are often managed by medication; and it is important for the clinician to be familiar with these medications to determine when to schedule dental appointments. In dealing with ADHD children, adjunctive behavioral strategies are often useful. Several basic techniques are discussed here.     

Is there a relationship between hyperactivity/inattention symptoms and poor oral health? Results from the GINIplus and LISAplus study

Objectives

A few clinical observations reported that children with attention deficit hyperactivity disorder (ADHD) have poor oral health compared to children without ADHD. However, evidence is not conclusive. We assess the association between hyperactivity/inattention and oral health in a population-based study.

Material and methods

As part of the ongoing birth cohort studies German Infant Nutritional Intervention-plus (GINIplus) and Influences of lifestyle-related factors on the immune system and the development of allergies in childhood-plus (LISAplus), 1,126 children at age 10 years (±10.2) from Munich (Germany) were included in the present analysis. During the dental examination, oral hygiene, non-cavitated and cavitated caries lesions, dental trauma, and enamel hypomineralization (EH) in the permanent dentition (MIH/1) were recorded. Children with a Molar-Incisor-Hypomineralization were subcategorized into those with EH on at least one first permanent molar (MIH/1A), and on at least one first permanent molar and permanent incisor (MIH/1B). Data on children’s hyperactivity/inattention symptoms were collected by parent-reported Strength and Difficulties Questionnaire. Logistic regressions and zero-inflated Poisson regression models were applied adjusted for gender, parental education, parental income, and methylphenidate or atomoxetine medication.

Results

Logistic regressions showed that non-cavitated caries lesions were positively related with the presence of hyperactivity/inattention (OR_adj?=?1.51,CI_95%?=?1.08–2.11). When adjusted for parental background, an association showed between hyperactivity/inattention symptoms and MIH/1A but did not reach statistical significance (OR_adj?=?1.59,CI_95%?=?1.00–2.53).

Conclusions

Children with borderline and abnormal values of hyperactivity/inattention symptoms showed more non-cavitated caries lesions. Severe levels of hyperactivity/inattention may contribute to a higher risk for MIH/1A in school age.

Clinical relevance

Adequate dental preventive care for children with hyperactivity/inattention, especially from a low social background, is of importance for optimal caries prevention.     

Salivary cortisol levels and dental anxiety in children with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder. The present study tested the hypotheses that children with ADHD, particularly those exhibiting severe hyperactivity and impulsivity, have a different stress reaction (measured by salivary cortisol) during a dental recall visit and are more dentally anxious than children in a control group. Eighteen children with ADHD and a control group of 71 children, all 13 yr of age, underwent a clinical dental examination and completed the Corah Dental Anxiety Scale (CDAS). Four saliva samples were gathered for analysis of cortisol: one prior to dental examination, one after, and two the following morning. The subgroup ADHD with hyperactivity/impulsivity had statistically significantly lower cortisol levels than the control group 30 min after awakening. When cortisol values were plotted on a timeline, this subgroup always had lower cortisol concentrations than children in the control group. There was a significant correlation between CDAS scores and cortisol concentrations prior to the dental examination in both the ADHD and the control group. Behavioral expressions of anxiety in children with ADHD may be different from those in other children, not only due to the characteristics of their disorder, but also because of lower stress reactivity.     

Oral health of children with attention deficit hyperactivity disorder

This study assessed and compared oral health and oral‐health behaviours among children with and without attention deficit hyperactivity disorder (ADHD). The study included 31 children, 12–18 yr of age, with ADHD and 31 age‐ and gender‐matched children without ADHD. Clinical data were recorded by a trained and calibrated examiner for caries, traumatic dental injuries, periodontal health, tooth wear, and salivary function. A questionnaire was also given to parents or caregivers about the oral health habits and behaviours of these children. Data were compared using Mann–Whitney U‐tests and chi‐square tests. No significant differences were found between children, with or without ADHD, in caries extent or prevalence, dental trauma prevalence, prevalence of periodontal disease or plaque, tooth wear, or unstimulated salivary flow. Children with ADHD had a significantly higher percentage of sites with gingival bleeding, as well as a higher frequency of parent‐reported dislike of dentists, bruxism, history of assisted toothbrushing, and toothbrushing duration <1 min. They also had higher attendance at government dental clinics. The findings indicate that children with ADHD have poorer oral hygiene and more adverse oral‐health attitudes and behaviours than do children without ADHD.     

The attention‐deficit/hyperactivity disorder model for traumatic dental injuries: a critical review and update of the last 10 years

It has been more than 10 years since the proposal of attention‐deficit/hyperactivity disorder (ADHD) model as an explanatory construct for traumatic dental injuries (TDIs) in children. The aim of this review was to address developments in the study of the issue after 2005–2016. A systematic literature search covering the period from 2005 to 2016 was conducted on PubMed, the Cochrane library and Google Scholar using relevant keywords. Fourteen studies exploring the relationship between ADHD and TDIs from 2005 and onward (including the proposal paper) were identified. Of the 12 controlled studies, nine reported confirming findings for a link with ADHD in the occurrence of TDIs. More than one‐third of all children with ADHD may suffer from TDIs. In ADHD children, the most common types of injury were uncomplicated/complicated crown fractures and subluxation of maxillary central incisors resulting from falls and collisions. There is also evidence that ADHD represents an independent risk factor other than the well‐established risk factor of incisor overjet. Over the last 10 years, convincing evidence has accumulated that ADHD is an important and common risk factor for TDIs. Increased awareness and side‐by‐side work of medical, dental and mental professionals at both clinical and research settings are necessary.     

Oral characteristics of children with attention-deficit hyperactivity disorder

The purpose of this study was to compare the oral and demographic characteristics of children with attention-deficit hyperactivity disorder (ADHD) to those of a control group of children. A sample of 25 dental records of children medicated for ADHD was compared to 127 records of healthy children not receiving any medication.
The children with ADHD had a statistically higher prevalence of toothache, bruxism, bleeding gums, and oral trauma histories than the control group (chi square, p < 0.05). The differences in other recorded oral characteristics and habits, such as plaque accumulation, gingival inflammation, calculus, oral hygiene compliance, dental caries experience, and unmet dental needs, were not statistically significant. The demographic characteristics such as age, gender, residence, ethnicity, income, and payment method were also not significantly different between the two groups.
There is a need to develop and implement specific strategies for the early prevention and treatment of oral diseases in children with ADHD.     

Dental caries in adolescents with attention deficit hyperactivity disorder: a population-based follow-up study

This study tested the hypothesis that adolescents with attention deficit hyperactivity disorder (ADHD) exhibit a higher prevalence of caries than adolescents in a control group. Thirty-two adolescents with ADHD and a control group of 55 adolescents from a population-based sample, all 17 yr of age, underwent a clinical and radiographic dental examination. The mean ± SD number of decayed surfaces (DS) was 2.0 ± 2.2 in adolescents with ADHD and 0.9 ± 1.4 in adolescents of the control group. Thirty-one per cent of the adolescents in the ADHD group had no new caries lesions (DS = 0) compared with 62% in the control group. Six per cent of the adolescents in the ADHD group were caries free [decayed, missing or filled surfaces (DMFS) = 0] compared with 29% in the control group. Adolescents with ADHD also had a higher percentage of gingival sites that exhibited bleeding on probing compared with the control group: 35 ± 39% vs. 16 ± 24% (mean ± SD), respectively. At 17 yr of age, adolescents with ADHD exhibited a statistically significantly higher prevalence of caries compared with an age-matched control group. Adolescents with ADHD need more support regarding oral hygiene and dietary habits. They should be followed up with shorter intervals between dental examinations to prevent caries progression during adulthood.     

Caries experience associated with attention-deficit/hyperactivity disorder

The purpose of this cross-sectional study was to examine whether children with attention-deficit/hyperactivity disorder (ADHD) had a total caries experience that was equivalent to children without the disorder. METHODS: The test sample included children ages 6 to 10 years old diagnosed with ADHD by physicians at Duke University Medical Center. The control group also included healthy children 6 to 10 years old without the diagnosis of ADHD. A visual dental exam for caries was performed and a sample of whole, unstimulated saliva was collected. The parent/guardian of each participant completed a health/medication history and a questionnaire concerning the child's oral health and habits, daily routine, and demographic information. RESULTS: Wilcoxon and chi-square tests showed that children with ADHD have significantly more enamel caries in the primary and permanent dentitions and a significantly higher prevalence of total caries experience when compared to controls. There was no significant difference in whole saliva production between the ADHD children and the controls. CONCLUSIONS: Dentists should be aware that children with ADHD are at higher risk for caries.     

How do children with attention deficit hyperactivity disorder interact in a clinical dental examination? A video analysis

Attention deficit hyperactivity disorder (ADHD) is currently the most common behavioural disorder in school-age children. The aim of this study was to perform a detailed analysis of behavioural interactions between the dentist and the child patient with ADHD. All children born in 1991 (n = 555) in one Swedish municipality were screened for attention and learning problems, and assessed for ADHD. Twenty-two children with ADHD, and a control group of 47 children without attention and learning problems, were included in the study. The dental recall visit was recorded on video. The interaction between the dentist and the child was analysed in detail and scored as verbal and non-verbal initiatives and responses. Compared to the children in the control group, the children with ADHD made significantly more initiatives, especially initiatives that did not focus on the examination or the dentist. The children with ADHD had fewer verbal responses and more missing responses. In conclusion, the problems in communication resulted in less two-way communication between the dentist and the children with ADHD than the interaction between the dentist and the children in the control group. The children with ADHD had particular difficulties staying focused on the examination.     

Attention deficit hyperactivity disorder. Literature review for the pediatric dentist

The purpose of this review was to give a complete summary of the ADHD (Attention Deficit Hyperactivity Disorder) for dentists, especially for those who deal with dental traumatology. Children with ADH disorder show symptoms of restlessness, hyperactivity, impulsive behaviour and inattention often resulting in serious dental accidents. The article summarizes the literary data concerning ADH-Syndrome, presents a typical case and also deals with the dental considerations.     

Dental injuries and attention‐deficit/hyperactivity disorder in children

The purpose of this study was to determine the relationship between attention‐deficit/hyperactivity disorder (ADHD) and traumatic dental injuries in children. A total of 194 children aged 7–15 years participated in this study. Fifty‐seven traumatic injuries to permanent teeth were observed in 33 children. Although a statistically significant difference was not found (p= .848), the rate of incidence was higher in the group with ADHD (17.5%) than in the control group (16.5%). The maxillary right central incisors accounted for nearly half of all injured teeth, while the maxillary central incisors represented the most frequently injured teeth. Enamel fracture was the most common type of dental injury observed. The incidence of enamel fracture was higher in the control group (66.7%) than in the subjects with ADHD (43.3%). There was a significant association between the occurrence of traumatic dental injury and the presence of an overjet greater than 3 mm (p= .020).     

The neuropathology, medical management and dental implications of autism

BACKGROUND: A paucity of information exists in the dental literature about autism and its dental implications. TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search for the period 2000 through 2006, using the term "autism," with the aim of defining the condition's clinical manifestations, dental and medical treatment and dental implications. RESULTS: Autism is a severe developmental brain disorder that appears in infancy, persists throughout life, and is characterized by impaired social interaction, abnormalities in communication (both verbal and nonverbal) and restricted interests. Often accompanying the disorder are behavioral disturbances - such as self-mutilation, aggression, psychiatric symptoms and seizures - that necessitate the administration of multiple medications to help the affected person participate effectively in the educational and rehabilitative process. CLINICAL IMPLICATIONS: Dentists caring for people with autism must be familiar with the manifestations of the disease and its associated features so that they can garner the maximum level of patient cooperation. They also must be familiar with the medications used to treat the associated features of the disorder because many of them cause untoward orofacial and systemic reactions and may precipitate adverse interactions with dental therapeutic agents.     

Is attention-deficit hyperactivity disorder a risk factor for dental caries? A case-control study

Experience in practice has suggested that children with attention-deficit hyperactivity disorder (ADHD) tend to have higher numbers of diseased, missing and filled teeth (DMFT score) than children without the condition. To date, however, this impression has not been systematically investigated. A case-control study of children in Otago, New Zealand (case DMFT > or = 5; control DMFT <5; case status determined from School Dental Service dental records) was conducted by postal survey and reference to the School Dental Service records. Cases and controls were matched on age, sex, ethnicity, and school socio-economic status. The purpose of the study was to assess whether having ADHD was associated with higher odds of having high caries experience. Questionnaires were returned for a total of 128 case-control pairs. Conditional logistical regression analysis showed that, after controlling for fluoride history, medical problems, diet, and self-reported oral hygiene, children with ADHD had nearly 12 times the odds of having a high DMFT score than children who did not have ADHD (OR = 11.98; 95% CI 1.13, 91.81). No other factors were significant predictors. Dental practitioners and parents should consider ADHD to be a condition that may affect children's dental caries experience.     

Overdiagnosis and medication for attention-deficit hyperactivity disorder in children with cleft: diagnostic examination and follow-up.

OBJECTIVE: To examine the diagnosis of attention-deficit hyperactivity disorder (ADHD) in children with cleft to determine whether language-learning characteristics are taken into account when making this diagnosis. DESIGN: Prospective examination of 177 consecutive patients. Objective behavioral ratings, cognitive assessments, and attention/impulsivity testing of 32 of the 177 children with nonsyndromic cleft lip and palate (CLP) who had previously been diagnosed as ADHD and were receiving medication were performed. the prospective 6- to 9-month follow-up examination was examined to determine the accuracy of prior and posttest diagnoses. SETTING: University hospital-based cleft palate clinic. MAIN OUTCOME MEASURES: Pretest/posttest design to determine accuracy of DSM-IV psychiatric diagnosis. RESULTS AND CONCLUSIONS: The results show that the proportion of children originally diagnosed with ADHD (18%) was significantly higher than posttest diagnosis of ADHD (6% p <.001). Also, the frequency of pretest diagnosis of learning disorder (LD; 31%) was significantly different from posttest diagnosis (66% p <.01). The overdiagnosis of ADHD and underdiagnosis of LD in this sample of children with nonsyndromic unilateral cleft lip and palate appears to be due to lack of language-learning assessment.     

Oral clefts and behavioral health of young children

Oral Diseases (2011) 18 , 74–84 Objectives: This study examined the behavioral health of young children with oral clefts, and effects of satisfaction with facial appearance, cleft team care, number of cleft‐related surgeries, and socioeconomic status (SES). Subjects and Methods: The study included a population‐based sample of 104 children aged 2–12 years with isolated oral clefts from the state of Iowa. Behavior was evaluated with the Child Behavior Checklist or the Pediatric Behavior Scale 30, depending on age, compared with normative samples. Results: Risks of behavioral problems were not significantly different from normative samples except for higher inattention/hyperactivity risks at age 6–12 years. Low satisfaction with facial appearance was associated with behavioral problems in all domains, except aggression. Team‐care effects were not associated with behavioral problems. Number of cleft‐related surgeries was associated with increased anxiety/depression and somatic symptom risks. Higher SES was associated with reduced inattention/hyperactivity, aggressive/oppositional behavior, and somatic symptoms. Conclusions: Most children with oral clefts may have similar behavioral health outcomes to unaffected children, except for increased inattention/hyperactivity risks at older ages. However, low satisfaction with facial appearance, increased exposure to surgeries, and lower SES may significantly increase behavioral problems. Also, the findings emphasize the need to study the representation of behavioral health professionals on cleft teams and access to behavioral health care.     

Dental caries and oral health behavior in children with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder. This study tested the hypothesis that children with ADHD exhibit a higher caries prevalence and poorer oral health behavior than children in a control group. Twenty-one children with ADHD and a control group of 79 children, all aged 13 yr, underwent a clinical dental examination and completed two questionnaires on dietary habits and dental hygiene habits. Differences between the groups regarding decayed, missed, or filled surfaces, decayed surfaces, initial caries lesions, and gingival inflammation were non-significant. Forty-eight percent in the ADHD group brushed their teeth every evening compared with 82% in the control group. The corresponding frequencies for brushing the teeth every morning were 48% and 75%. Children with ADHD were 1.74 times more likely to eat or drink more than five times a day than children in the control group. In conclusion, at age 13, children with ADHD do not exhibit a statistically significantly higher caries prevalence but do have poorer oral health behavior than children in a control group. The intervals between dental examinations of children with ADHD should be shorter than for other children to prevent a higher caries incidence in adolescence because of their oral health behavior.