General Dental Considerations
Oral Findings
Poor oral hygiene due to reduced attention span and compliance for tooth brushing
Increased caries and periodontal disease
Bruxism
Higher risk for dental/oral trauma due to inattention, impulsivity
Adults are at potentially high risk for periodontal disease and oral cancer due to high rates of smoking
Medication‐related side‐effects including xerostomia, dysphagia, dysgeusia, bruxism, angio‐oedema, glossitis and orofacial dyskinesias
Dental Management
Compliance for the delivery of dental care can vary (Table 2.1.1)
Treatment should be modified based on reassessment of the patient on the day of the appointment
Section II: Background Information and Guidelines
Definition
ADHD, once called hyperkinesis or minimal brain dysfunction, is a disorder that interferes with the ability to persist in a task and to exercise age‐appropriate inhibition. It affects 3–5% of children and is twice as common in boys as in girls. It often continues into adolescence and adulthood.
Aetiopathogenesis
The main cause is unclear
Physical triggers: hyperkinetic syndrome, brain damage, low intelligence, anxiety states, drug abuse, high intake of refined sugar and food additives (e.g. tartrazine sensitivity)
Social triggers: child–parent relationship, rejection or overprotection, inconsistent discipline, lack of parental love, marital disharmony, depression, institutionalised, excessive demands from school
Evidence for familial predisposition
Clinical Presentation
ADHD is characterised by inattention and hyperactivity and/or impulsivity, which are excessive, long‐term and pervasive
Signs of inattention include:Becoming easily distracted by irrelevant sights and soundsFailing to pay attention to details and making careless mistakesRarely following instructions carefully and completelyTable 2.1.1 Considerations for dental management.Risk assessmentInappropriate behaviour with uncontrolled movements or aggressionLack of attention with tendency to stand up suddenly and explore surroundings/leave the clinic roomThis may cause distress and potential injury for staff and the patientContamination of surfaces may occur as the patient explores and examines the contents of surgery and cupboardsDental treatment may be considered an exhausting experience for both the patient and the dental teamPotential interaction of dental local anaesthetics with medications used to manage ADHDCriteria for referralPatients with very disruptive behaviour who may require pharmacological adjuncts to enable dental treatment to be undertaken safely may be treated in specialist dental servicesAccess/positionEnsure an appropriate escort is availableConsult parents/escort as to the most suitable time of day to arrange an appointmentDo not interrupt meals or prescheduled activitiesAppointments need to be short with no waiting time before the patient is seenCommunicationEnsure that language and sentences are kept short and simpleUse visual aids such as pictures or videos so that parents can run ‘training sessions’ at home regarding the process of visiting the dentistPsychological support from the patient's care team may also be availableCapacity/consentExplanation of the planned procedure should be provided using simple terminology and short sentencesParents/guardians (for children)/appropriate escorts should be involved in the consent processAnaesthesia/sedationLocal anaesthesiaThe administration of local anaesthesia solutions containing vasopressors, such as levonordefrin, epinephrine or norepinephrine, to patients receiving tricyclic antidepressants or monoamine oxidase inhibitors should be avoided if possible as it may produce severe, prolonged hypertension and tachycardiaIn situations when concurrent therapy is necessary, careful patient monitoring is essentialPatient may need manageable reassurance‘Tell–show–do’ may be of value especially when applied by a dentist trained in child psychologyIf cannot be given safely, alternative approaches should be consideredSedationOrally administered agents, such as diazepam, should be avoided as they exacerbate rather than depress overactivityRelative analgesia using nitrous oxide and oxygen may be usefulAlthough intravenous sedation may be used, the success of sedation is unpredictable, the outcome of previous sedations being the best prognosis indicatorGeneral anaesthesiaPatients requiring complex dental treatment and those uncontrolled with sedation may be treated with general anaesthesiaAdmission to hospital may be problematic and a single side room may be requiredDental treatmentBeforeEnsure that a risk assessment has been completed and the team has been briefed regarding any disruptive/aggressive behaviourIf appropriate, consent and arrangements for safe and approved clinical holding need to be formally recorded and reviewed on the day of treatmentRemove all equipment and items from the surgery which are not neededDuringAdditional caution when performing invasive proceduresTerminate treatment if the patient becomes distressed or there are safety issuesAfterGive positive reassuranceRe‐evaluate next stepsDrug prescriptionIdiosyncratic reactions to diazepam and midazolam have been observedEducation/preventionMost patients need assistance to brush their teethElectronic toothbrushes are often not well tolerated due to the vibration and soundImplement fluoride supplementation in line with dental caries riskDietary advice to reduce caries riskMore regular reviews and shorter recall intervals advisableLosing or forgetting things such as toys, pencils, books and tools needed for the task
Signs of hyperactivity and impulsivity include:Persistent motion and seem unable to curb their immediate reactions or think before they actFeeling restlessOften fidgeting with hands or feetSquirmingRunningClimbingLeaving a seat when situations where sitting and quiet behaviour are expectedBlurting out an answer before hearing the questionDifficulty waiting in a queue or for a turn
Commonly associated disorders may include:Oppositional defiant disordersDevelopmental language disordersMotor and co‐ordination difficultiesLearning disabilityTourette syndrome – an inherited neurological disorder characterised by repeated and involuntary body movements (tics) and uncontrollable vocal sounds and words (coprolalia)Epilepsy; ~20% of children with epilepsy have ADHDNon‐restorative sleep due to insomnia, sleep apnoea, circadian rhythm disturbances, restless leg syndrome and parasomnias
Although parents frequently describe their child as ‘overactive’, the term should be limited to those who demonstrate gross behavioural abnormalities, including uncontrolled activity, impulsiveness, impaired concentration, motor restlessness and extreme fidgeting
These activities are seen particularly when orderliness is required – for example, in a waiting room or surgery
Diagnosis
The diagnosis is mainly established on clinical findings
In DSM‐V, ADHD is included in the section on neurodevelopmental disorders, rather than being grouped with the disruptive behaviour disorders – this change better reflects the way ADHD is currently conceptualised
DSM‐V has also revised the age of onset criteria to ‘several inattentive or hyperactive‐impulsive symptoms present prior to 12