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ORAL CHARACTERISTICS OF CHILDREN WITH ADHD ARTICLE Spec Care Dentist 28(3) 2008 107 ©2008 Special Care Dentistry Association and Wiley Periodicals, Inc. doi: 10.1111/j.1754-4505.2008.00021.x ABSTRACT The purpose of this study was to com- pare the oral and demographic characteristics of children with atten- tion-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 chil- dren not receiving any medication. The children with ADHD had a statis- tically 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 expe- rience, and unmet dental needs, were not statistically significant. The demo- graphic characteristics such as age, gender, residence, ethnicity, income, and payment method were also not sig- nificantly different between the two groups. There is a need to develop and imple- ment specific strategies for the early prevention and treatment of oral dis- eases in children with ADHD. Oral characteristics of children with attention-deficit hyperactivity disorder Enrique Bimstein, CD (México); 1* John Wilson, DDS; 2 Marcio Guelmann, DDS; 3 Robert Primosch, DDS, MS, MEd 4 1 Professor, Department of Pediatric Dentistry; 2 Student; 3 Associate Professor and Chair, Department of Pediatric Dentistry; 4 Associate Dean for Education and Professor, Department of Pediatric Dentistry, University of Florida College of Dentistry. * Corresponding author e-mail: [email protected] Spec Care Dentist 28(3): 107-110, 2008 Although ADHD has been described as the most widely studied behavioral/ emotional syndrome in children, 2 the number of reports on the dental aspects of ADHD is low and their findings need validation. The purpose of this study was to compare the oral and associated demographic characteristics of a clinical sample of children with ADHD to a con- trol group of children without ADHD. Materials and methods After approval by the Institutional Review Board for Research on Human Subjects of the University of Florida, a sample consisting of 300 dental charts of children examined in three pediatric den- tistry clinics (100 charts from each clinic) was randomly selected. The clin- ics were located at: (1) the College of Dentistry at an urban university campus; (2) a community-based healthcare facil- ity in an urban area; and (3) a community- based healthcare facility in a rural area. All three dental clinics had a mission to serve underprivileged patients. Clear and complete information on the systemic and mental condition of each child was available from the parent-completed health history form used for 291 chil- dren. Dental students or residents from the Department of Pediatric Dentistry confirmed the information provided by the parents and carried out a clinical examination. The health history and Introduction Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder charac- terized by pervasive inattention and/or hyperactivity-impulsivity, which can result in significant functional impairment. 1 This condition has been described as the most common behavioral disorder of childhood and the most widely studied, but the condi- tion still elicits controversies and differences of opinion. 2 Depending upon the sampling strategies, methodological differences, and diagnostic criteria of the studies, the esti- mated prevalence of ADHD ranges from 3% to 18%. 2-6 Persons with ADHD have difficulties with communication, overactivity, impulsivity, and staying focused, which can make a dental examination challenging. 7-11 However, some authors have reported that children with ADHD behaved similarly to children without the condition 12 or that they had similar levels of dental anxiety. 13 Other studies have reported that these children have poor oral hygiene, which can result in a higher incidence of oral diseases, 13-15 and that they have a higher prevalence of dyskinesia and bruxism 16-17 and dental trauma. 18-19 It has also been reported that children with ADHD have idiosyncratic reactions to the sedative agent midazolam HCl 20 and that medica- tions used for the treatment of ADHD produce xerostomia, 21 which may facilitate the development of dental caries. KEY WORDS: oral disease, ADHD

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Page 1: Oral characteristics of children with attention-deficit hyperactivity disorder

O R A L C H A R A C T E R I S T I C S O F C H I L D R E N W I T H A D H D

A R T I C L E

Spec Care Dent is t 28(3 ) 2008 107©2008 Special Care Dentistry Association and Wiley Periodicals, Inc.doi: 10.1111/j.1754-4505.2008.00021.x

A B S T R A C TThe purpose of this study was to com-pare the oral and demographiccharacteristics of children with atten-tion-deficit hyperactivity disorder(ADHD) to those of a control group ofchildren. A sample of 25 dental recordsof children medicated for ADHD wascompared to 127 records of healthy chil-dren not receiving any medication.

The children with ADHD had a statis-tically higher prevalence of toothache,bruxism, bleeding gums, and oral traumahistories than the control group (chisquare, p < 0.05). The differences inother recorded oral characteristics andhabits, such as plaque accumulation,gingival inflammation, calculus, oralhygiene compliance, dental caries expe-rience, and unmet dental needs, werenot statistically significant. The demo-graphic characteristics such as age,gender, residence, ethnicity, income,and payment method were also not sig-nificantly different between the twogroups.

There is a need to develop and imple-ment specific strategies for the earlyprevention and treatment of oral dis-eases in children with ADHD.

Oral characteristics of children withattention-deficit hyperactivity disorder

Enrique Bimstein, CD (México);1* John Wilson, DDS;2 Marcio Guelmann, DDS;3

Robert Primosch, DDS, MS, MEd4

1Professor, Department of Pediatric Dentistry; 2Student; 3Associate Professor and Chair, Department

of Pediatric Dentistry; 4Associate Dean for Education and Professor, Department of Pediatric

Dentistry, University of Florida College of Dentistry. *Corresponding author e-mail: [email protected]

Spec Care Dentist 28(3): 107-110, 2008

Although ADHD has been describedas the most widely studied behavioral/emotional syndrome in children,2 thenumber of reports on the dental aspectsof ADHD is low and their findings needvalidation. The purpose of this study wasto compare the oral and associateddemographic characteristics of a clinicalsample of children with ADHD to a con-trol group of children without ADHD.

Mate r i a l s and me thodsAfter approval by the InstitutionalReview Board for Research on HumanSubjects of the University of Florida, asample consisting of 300 dental charts ofchildren examined in three pediatric den-

tistry clinics (100 charts from eachclinic) was randomly selected. The clin-ics were located at: (1) the College ofDentistry at an urban university campus;(2) a community-based healthcare facil-ity in an urban area; and (3) a community-based healthcare facility in a rural area.All three dental clinics had a mission toserve underprivileged patients. Clear andcomplete information on the systemicand mental condition of each child wasavailable from the parent-completedhealth history form used for 291 chil-dren. Dental students or residents fromthe Department of Pediatric Dentistryconfirmed the information provided bythe parents and carried out a clinicalexamination. The health history and

I n t r oduc t i onAttention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder charac-terized by pervasive inattention and/or hyperactivity-impulsivity, which can result insignificant functional impairment.1 This condition has been described as the mostcommon behavioral disorder of childhood and the most widely studied, but the condi-tion still elicits controversies and differences of opinion.2 Depending upon the samplingstrategies, methodological differences, and diagnostic criteria of the studies, the esti-mated prevalence of ADHD ranges from 3% to 18%.2-6

Persons with ADHD have difficulties with communication, overactivity, impulsivity,and staying focused, which can make a dental examination challenging.7-11 However,some authors have reported that children with ADHD behaved similarly to childrenwithout the condition12 or that they had similar levels of dental anxiety.13 Other studieshave reported that these children have poor oral hygiene, which can result in a higherincidence of oral diseases,13-15 and that they have a higher prevalence of dyskinesia andbruxism16-17 and dental trauma.18-19 It has also been reported that children with ADHDhave idiosyncratic reactions to the sedative agent midazolam HCl20 and that medica-tions used for the treatment of ADHD produce xerostomia,21 which may facilitate thedevelopment of dental caries.

KEY WORDS: oral disease, ADHD

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clinical examinations were reviewed byfaculty members from the Department ofPediatric Dentistry at the University ofFlorida. From the sample of 291 dentalcharts, 127 children (43.6%) had noreport of any systemic or mental disabil-ity and 164 (56.4%) had a reportedsystemic or mental disability. Among thelatter group, 25 children (8.6% of thesample) received specific medication forthe treatment of ADHD. Due to the retro-spective nature of this study, no intra-and inter-examiner reliability tests werepossible. In this study, the informationobtained from the 25 children withADHD (ADHD group) was compared tothe data on the 127 children in thehealthy control group.

The following information, whichhad been reported by a parent at the firstexamination, was recorded for this study:chronological age of the child in months;gender; ethnic origin (Caucasian, AfricanAmerican, Hispanic, other); rural orurban residence (population of fewer ormore than 20,000 individuals, respec-tively); low or high annual householdincome (less than or more than $30,000U.S., respectively); method of paymentfor dental care (private or insurance);histories of toothache, bleeding gums,oral trauma, or bruxism (tooth-grindingduring sleep); and compliance with dailyoral hygiene (personal or adult-supervised toothbrushing/flossing).

The oral characteristics of the chil-dren were recorded as a global value forthe whole mouth during the first dentalexamination using the following scoringsystems: plaque index (0 = no plaque, 1 = isolated plaque deposits, 2 = general-ized plaque deposits, 3 = heavy plaquedeposits); gingival index (0 = no inflam-mation, 1 = inflammation with nobleeding on probing, 2 = inflammationwith bleeding on probing, 3 = sponta-neous bleeding); and calculus index (0 =no calculus, 1 = light, 2 = moderate, 3 =heavy). For the statistical examination,the plaque, gingival inflammation, andcalculus scores were recorded as either 0(not present) or ≥ 1 (present). Thecumulative severity of caries experienceas the total number of decayed and filledsurfaces in the primary and permanent

teeth was based on the clinical and radi-ographic examinations. The presence ofmissing teeth was not recorded due tothe difficulty of determining whether aprimary tooth was missing due to acaries-related extraction, orthodontictreatment, or normal exfoliation. Theunmet needs score for each group wascalculated with the formula [(Decayedsurfaces / Filled + Decayed surfaces) �100]. It should be noted that since cer-tain data was unclear or missing in somecharts, the data analyses did not alwaysinclude all of the children.

The statistical analyses were per-formed with the help of a standardstatistical program (JMP, version 6, 2005,SAS Institute Inc., Cary, N.C., USA); t-tests were used to determine the statis-tical significance of between-groupdifferences in continuous variables, andchi square tests were used for categoricalvariables.

Resu l t sThe mean chronological age of the chil-dren was 88.6 months (SD = 42.9). Thedifference in age between the group withADHD (mean: 90.4, SD: 39.6 months)and the control group (mean: 88.2, SD:43.6 months) was not statistically signifi-cant (t-test, p ≥ 0.05). The paymentmethod for dental care for most of thechildren was state-assisted [Medicaid(68.5%) or Children’s Medical Services(7.0%)]; other forms of insurance wereused by 9.1% of the families and only15.4% of the families paid a private fee.When considering all the methods ofpayment, a statistically significant differ-ence in the distribution was found (chisquare, p = 0.03), with private pay beingreported for one child (4.0%) in thegroup with ADHD and 21 children(16.5%) in the control group.

Analysis of the differences betweenthe two study groups in the distributionof demographic characteristics failed toindicate any statistically significant dif-ferences (Table 1). Analysis of the oralcharacteristics (Table 2) suggested thatsubjects in the group with ADHD had astatistically higher prevalence of parentsreporting previous toothache, bruxism,

bleeding gums, and oral trauma. The twogroups did not differ in their examiner-recorded oral hygiene characteristics(Table 2). There were some apparent dif-ferences between the two groups in thecumulative number of filled or carioussurfaces and in their unmet treatmentneeds (Table 3), but these differenceswere also not statistically significant.

Di scus s i onThe review of charts of children whowere examined and treated by studentsand residents of a College of Dentistryshowed a prevalence of ADHD to be8.6%, a male to female ratio of 2:1, witha higher prevalence of ADHD inCaucasians than in African Americans.A higher number of filled or carioussurfaces and unmet treatment needswereas found in children with ADHDcompared to the control group ofhealthy children, but it was not statisti-cally significant.

To interpret the findings, one shouldconsider that this study had several limi-tations in methodology; it wasretrospective and did not include calibra-tion among the multiple examiners.Previous studies13-15 have had larger sam-ples or were matched case-control studydesigns, which provided stronger evi-dence. Nevertheless, the informationprovided by the parents and the clinicalfindings in our study may still be indica-tive of the oral characteristics of childrenwith ADHD.

The 8.6% prevalence of ADHD foundin this study was in agreement with pre-vious findings for the state of Florida,1

and the oral health histories reported bythe parents supported previous reports16-19

indicating that children with ADHD hada higher prevalence of bruxism, gingivalinflammation, and oral trauma. On theother hand, our finding of a male tofemale ratio of 2:1 differed from previ-ous studies, whose ratios have rangedfrom 6:1 to 3:1.2 The distribution ofADHD by ethnic origin in our studyindicated a higher prevalence of ADHDin Caucasian than in African Americanchildren whereas previous studies indi-cated the opposite.22 These differences

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may be the result of the influence ofpopulation characteristics such as eco-nomic status.

Previous investigations and our studyindicated that the dental treatment forchildren with ADHD should include anunderstanding of their behavior manage-ment needs. Dental professionals andparents should also be aware of the pos-sibility of increased susceptibility to oraldiseases in children with ADHD.However, additional studies with bettermethodologies are still required to clarifyprevious findings.

Conc lu s i onsThe behavioral traits of children withADHD and their influence on oral healthsuggest the need for the developmentand implementation of specific strategiesfor the prevention and treatment of theiroral diseases.

Re fe r ences1. Department of Health and Human Services.

Centers for Disease Control and Prevention.

USA government. Attention-deficit/hyperac-

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http://www.cdc.gov/ncbddd/adhd/, accessed

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2. Jensen PS. Department of Health and

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Table 1. Demographic characteristics of children in the groupwith ADHD and the control group (recorded from dental charts).

ADHD Control p

n % n %

Gender Male 15 60 55 43

Female 10 40 72 57 NS

Residence Urban 13 52 75 59

Rural 12 48 52 41 NS

Ethnicity Caucasian 10 71 39 54

African American 4 29 24 32

Hispanic and “other” 0 0 9 14 NS

Income Low 8 67 35 63

High 4 33 21 37 NS

Table 2. Oral characteristics of children in the group with ADHDand the control group.

ADHD Control p

n % n %

Toothache history Present 10 43 24 20

Absent 13 57 98 80 0.01

Bruxism history Present 6 43 8 8

Absent 8 57 95 92 0.001

Bleeding gums history Present 7 30 11 9

Absent 16 70 108 91 0.01

Oral trauma history Present 6 26 7 6

Absent 17 74 108 94 0.008

Plaque Present 10 83 76 86

Absent 2 17 12 14 NS

Gingival inflammation Present 8 73 57 65

Absent 3 27 31 35 NS

Calculus Present 4 57 19 30

Absent 3 43 45 70 NS

Personal toothbrushing Present 21 95 114 100

Absent 1 5 0 0 NS

Supervised toothbrushing Present 14 67 50 46

Absent 7 33 58 54 NS

Flossing Present 3 27 25 26

Absent 8 73 71 74 NS

Table 3. Mean and standard deviation (SD) of carious or filledtooth surfaces and unmet treatment needs scores by group.

ADHD Control p

mean SD mean SD

Carious surfaces 8.1 12.1 6.5 7.1 NS

Filled surfaces 1.3 3.0 1.6 3.8 NS

Unmet treatment needs 76.9 36.9 81.6 30.8 NS

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