Dr.

UMAMAHESWARI S
1ST YEAR PG
ADHIPARASAKTHI DENTAL COLLEGE AND HOSPITAL
A RUN THROUGH OF ADHD
DEFINITION:

 ADHD refers to a family of related chronic neurobiological disorders that

interferes with an individual's capacity to regulate activity level
(hyperactivity),inhibit behavior (impulsivity)and attend to tasks
(inattention) in developmentally appropriate ways.
 Attention deficit Hyperactive Disorder (ADHD) is defined as a persistent
pattern of inattention and/or hyperactivity–impulsivity that interferes with
functioning or development, has symptoms presenting in two or more
settings (e.g., at home, school, or work; with friends or relatives; in other
activities), and negatively impacts directly on social, academic, or
occupational functioning(APS) 2013

DSM-5 Diagnostic Criteria for ADHD(2013) American Psychiatric Association criteria for ADHD
jl. of Clin Ped Dent Vol.34.No .1 .2009
 ETIOLOGY:

 GENETIC
 ENVIRONMENTAL
 BIOLOGICAL
 PSYCHOSOCIAL ADHD

A large-scale twin study by

Levy et al estimated ADHD
to be 70 to 90% heritable.

Pedodontic Considerations in a Child with Attention Deficit Hyperactivity Disorder,IJCPD,2018

Management for Caries Prevention in ADHD Children,Int. J. Environ. Res. Public Health 2022,
 • Consistent with both types.
COMBINED • Most prevalent
TYPES(ACCORDING TO DSM (IV):

PRIMARILY
• Formerly known as attention deficit disorder
• Second most common
INATTENTIVE

PRIMARILY evident
• Not reached the age where attention becomes
HYPERACTIVE/ • Frequently described in very young children
IMPULSIVE

Pedodontic Considerations in a Child with Attention Deficit Hyperactivity Disorder,IJCPD ,2018

Management for Caries Prevention in ADHD Children,Int. J. Environ. Res. Public Health 2022,
 ACCORDING TO DSM (V):
THE FOURTH SUBTYPE:

 Inattentive (restrictive), where the criterion for inattentive is met but

no more than two symptoms from hyperactive/impulsive have been
present for the last 6 months.

International Journal of Pediatrics,Prevalence of ADHD in children aged 5-12 years in urban schools of Bengaluru.April 20, 2017
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V™) American Psychiatric Association(2013)
 CLINICAL FEATURES:
 It is a developmental disorder.
 Onset : Before the age of 4.
 Carelesssness
 Forgetfulness
 Day dreaming
 Excessive talking
 Disoragnization
 Risky behavior

The pathophysiology, medical management and dental implications of adult attention-deficit/hyperactivity disorder. J Am Dent Assoc
2007
Attention deficit hyperactivity disor_x0002_der: a review and guide for dental professionals. J Disability Oral Health 2002;
DIAGNOSTIC CRITERIA:
INATTENTIVE TYPE:
 Displays poor listening skills
 Loses and/or misplaces items needed to complete activities or tasks
 Sidetracked by external or unimportant stimuli
 Forgets daily activities
 Diminished attention span
 Lacks ability to complete schoolwork and other assignments or to follow
instructions
 Avoids or is disinclined to begin homework or activities requiring
concentration
 Fails to focus
DSM-5 Diagnostic Criteria for ADHD(2013) American Psychiatric Association
HYPERACTIVE/IMPULSIVE TYPE:

 Squirms when seated or fidgets with feet/hands

 Marked restlessness that is difficult to control
 Appears to be driven by “a motor” or is often “on the go”
 Lacks ability to play and engage in leisure activities in a quiet manner
 Incapable of staying seated in class
 Overly talkative

DSM-5 Diagnostic Criteria for ADHD(2013) American Psychiatric Association criteria for ADHD
 DENTAL IMPLICATIONS:

MOLAR INCISOR
POOR ORAL HYGIENE HYPOMINERALISATION NAIL BITING

BRUXISM TRAUMATIC INJURIES PHYSICAL ABUSE

 TREATMENT MODALITIES:

Management of the child with ADHD involves four broad

approaches:
 Behavior modification
 Educational (counseling)
 Pharmacological
 Lifestyle changes
Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder.Am Fam Physician 2009 Apr 15
Behaviors of children with and without attention deficit hyperactivity disorder during a dental recall visit. ASDC J Dent Child 2000 Jul-Aug;67
 BEHAVIOUR MODIFICATIONS
PHARMACOLOGICAL NON PHARMACOLOGICAL

1) Preappointment preparation
1. Psychostimulant 2) Tell-Show-Do method
2. Methylphenidate (Ritalin) 3) Repetition of instructions.
and Dexampheamine 4) Early morning appoinments
3. Antihypertensive clonidine, 5) Multiple short visits
Antidepressants 6) Use of frequent breaks
occasionally neuroleptics.
7) Clear and simple instructions
8) Praise and encouragement
9) Use of protective stabilization (
Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder.Am Fam Physician 2009 Apr 15
Oral health, dental anxiety, and behavior management problems in children with attention deficit hyperactivity disorder. European Journal of Oral Sciences,
114(5)
 SPECIAL CARE:
PARENTAL SUPERVISION HOME CARE INSTRUCTIONS

ANTICIPATORY GUIDNACE OCCLUSAL SPLINTS

DISCUSSION:

 The ADHD patients present a unique challenge to the pedodontic team.

However, with careful evaluation of their treatment needs and cooperative
ability, they can be satisfactorily treated.
 Lalloo concluded that hyperactive children were twice as likely to experience
an injury to the face and/or teeth as compared with the control group based on
data from the 1997 Health Survey of England.

Oral characteristics of children with attention-deficit hyperactivity disorder. Spec Care Dentist 2008 May-Jun;28
A review of attention-deficit/hyperactivity disorder from the dental perspective. N Z Dent J 2012 Sep;3
  A prospective study comparing the use of GA for children with and without
ADHD undergoing elective surgery showed that induction procedures can
be extremely challenging in those with ADHD, and that there was an
increase in maladaptive behavior postoperatively.

 Children with ADHD treated with methylphenidate-based drugs showed

lower values of non-stimulated saliva, higher dental caries and plaque
indices in comparison to children treated only using nonpharmacological
methods.

Anesthesia induction, emergence, and postoperative behaviors in children with attention-deficit/hyperactivity disorders. Paediatric Anaesthesia 2010 Apr;20
Unexpected interaction of methylphenidate (Ritalin) with anesthetic agents. Paediatric Anaesth 1997;7
Pharmacologic behavior management of pediatric dental patients diagnosed with ADHD,Pediatric dentistry,2007
  Broadbent et al (2004)showed that children with ADHD are twice as likely to be
in the high-caries risk group.
 Bimstein et al., (2008 ) ADHD condition may affect children’s oral health.
 Blomqvist et al., (2006) ADHD children desire an intensive oral health control.
 Blomqvist et al., (2007) ADHD condition indicates for shorter intervals between
dental examinations.

Oral Health, Dental Anxiety, and Behavior Management Problems in Children with Attention Deficit Hyperactivity Disorder. Eur. J. Oral Sci. 2006
Excessive weight gain and dental caries experience among children affected by ADHD. Int. J.Environ. Res. Public Health 2020
Oral characteristics of children with attention-deficit hyperactivity disorder Spec. Care Dent. 2008,
  Hidas et al., (2011) ADHD condition may be a factor contributing to caries
in older age.
 Chau et al., (2016) stated that ADHD children have poorer oral hygiene,
more adverse oral-health attitudes.
 Begnini et al., (2019) ADHD children need supervision on oral health
 Lower activity of salivary glands were found in a study by Vafaei et
al.Children with ADHD showed low values of non-stimulated saliva, higher
dental caries and plaque indices in comparison to children treated only using
nonpharmacological methods

Comparison of the Effect of Pharmacotherapy and Neuro-Feedback Therapy on Oral Health of Children with ADHD J. Clin. Exp. Dent. 2018,
Oral Health Status, Salivary Flow Rate and Salivary Quality in Children, Adolescents and Young Adults with ADHD. Arch. Oral Biol. 2011
Oral Health of Children and Adolescents withAttention Deficit Hyperactivity Disorder. Int. J. Clin. Pediatr. Dent. 2019,,
  Ehlers et al.,(2019) stated that parents/guardians need instructions for better
supervision of oral hygiene and dietary habits.
 Paszynska et al.,(2020)stated that limiting sugar consumption might be one of
preventive point against dental caries and overweight/obesity.
 Additionally, anthropometric studies indicated that children with ADHD may
represent a population at risk of overweight which might be related to binge
eating disorders (BED), impulsiveness and abnormal foodbehaviors, mainly in
the form of periodical episodes

Dental Management Considerations in Children with Attention-Deficit Hyperactivity Disorder.ASDC J. Dent. Child
Overweight in Boys: Cross-Sectional Study with Birth Weight as a Controlled Factor. Eur. Child Adolesc. Psychiatry 2015,.
Oral health of children and adolescents with or without attention deficit hyperactivity disorder (ADHD) living in residential care in rural Rhineland-Palatinate,
CONCLUSION:

 The pedodontist should be knowledgeable to be in the

forefront to make
 Accurate diagnosis,
 Use appropriate behavior management techniques,
 Render prompt treatment with recurrent follow-up
 To make referral to the pediatrician and neurologists for
promotion of good general and oral health of the
patient.
 Early strategies for individual patient cases and choices
of remineralization products are needed to defend the
oral health of children with ADHD against dental caries.
TAKE HOME MESSAGE:

 Proper HISTORY of the children with ADHD

 Arrive at an prompt Diagnosis
 The diagnosed child should be treated with best possible care both
effectively and efficiently.
 For increasing the attention span indulge them in activities that require
significant amount of concentration, such as video-games and tasks to
arrange the colored blocks in a specific order,etc
 Effective preventive measures should be made depending on the level of
caries risk, patient’s cooperation and therapeutic management.