By Dr. Greg Grillo
Attention deficit hyperactivity disorder (ADHD) is a common mental health condition characterized by a short attention span, hyperactivity, and difficulty controlling impulsive behaviors. It is one of the most commonly diagnosed childhood neurodevelopmental disorders and often lasts into adolescence and adulthood.
Since people with ADHD often have trouble sitting still for extended periods, it can be especially difficult for them to go to the dentist and sit through long dental appointments, which can cause them to feel anxious and stressed out.
Children with ADHD are often forgetful about brushing their teeth and have trouble carrying out motor skills such as tooth brushing, contributing to poor oral hygiene. They also have a higher prevalence of cavities and are more susceptible to traumatic dental injuries.1
Finding a good dental professional can help patients with ADHD feel more comfortable during appointments and help them develop healthy oral hygiene habits. Furthermore, coordinated efforts by dentists and a family member can help create essential support needed by patients with ADHD.
This article provides insights on the maintenance of oral health in patients with ADHD, its importance, and the techniques that can be employed to ensure healthy oral hygiene habits.
Oral Health in Patients With ADHD
Children with ADHD have a poorer overall oral health status than those without ADHD. Poor oral hygiene habits contribute to a higher prevalence of dental caries in children with ADHD. The inability to focus, short attention span, and poor motor skills are the reasons for less effective tooth brushing, resulting in poor oral health.
Additionally, children with ADHD are more prone to traumatic dental injuries caused by cognitive impairment, motor control impairment, and violent behaviors, which are common comorbidities of ADHD. Dental traumatic injuries can also affect the psychological well-being of children with ADHD since they may avoid smiling or laughing to avoid showing their teeth, which can bring them shame.2
Adults with ADHD may have minor physical abnormalities such as a high arched palate caused by orofacial injuries from automobile accidents resulting from their impulsive behavior, inattention, and impaired reaction time. Impulsivity and inattention can also make it difficult for patients with ADHD to comply with their oral hygiene home-care regimens, compromising their dental health.
Moreover, adults with ADHD may self-medicate by smoking cigarettes to reduce ADHD symptoms, which can cause oral cancer and periodontal disease. The frequent consumption of caffeinated beverages by many patients with ADHD to improve their cognitive abilities can also harm oral health by staining teeth or producing dental caries.3
The oral health of patients with ADHD can also be affected by psychostimulants commonly used to treat ADHD. Several side effects of psychostimulants threaten the oral and dental care of patients with ADHD, including dental erosion and gingival overgrowth.
Studies have shown that a low unstimulated salivary flow rate is observed in patients with ADHD, which can cause oral health problems such as dental caries, halitosis, and plaque accumulation. Furthermore, drugs used for treating ADHD can also cause adverse side effects like xerostomia.4
Complications of Poor Oral Hygiene in Patients With ADHD
The above sections explain how patients with ADHD often have worse overall oral health compared to those without ADHD. So, improving oral hygiene practices in patients with ADHD is essential, even though it can be challenging.
Good oral health habits can help them prevent any serious oral health complications in the future, which may be costly, difficult to cure, and require complex medical procedures. The following complications can be caused by poor oral hygiene practices in patients with ADHD.
Xerostomia is a condition where the mouth’s salivary glands do not make enough saliva. Adequate saliva is necessary since it helps moisten and cleanse the mouth, digest food, and control the number of bacteria and fungi in the mouth, preventing infections. In these ways, xerostomia contributes to dental caries, dental diseases, and oral pain.
Moreover, xerostomia can impair chewing ability and decrease taste sensation, diminishing quality of life. Xerostomia can also impair speech and cause cracks and fissures in the oral mucosa. Furthermore, xerostomia can cause sleep disturbances due to the need to wake up and quench one’s dry mouth. Many medications, including those used for treating ADHD, cause xerostomia. Xerostomia can easily be addressed and treated by dental care professionals.
Dental trauma is one of the most serious oral conditions in children and adolescents. Dental complications associated with traumatic dental injuries include anterior fractures that cause functional problems and aesthetic issues, tooth discoloration, pulp necrosis, pulp canal obliteration, root resorption, and loss of marginal alveolar bone.
Children with ADHD have a higher prevalence of traumatic dental injuries than those without it, mainly due to hyperactivity, impulsivity, and violent behaviors associated with the condition.5
Bruxism is the involuntary grinding or clenching of teeth while awake or asleep. Severe bruxism can lead to damaged teeth, increased tooth pain and sensitivity, worn tooth enamel, jaw disorders, headaches, and other problems. Medications used to treat ADHD cause a higher occurrence of bruxism in patients with ADHD.6
Poor oral health habits can lead to toothaches, bleeding gums, and gum and jaw aches, which all cause significant oral pain.
Oral diseases include dental caries, periodontal disease, oral mucosal lesions, and tooth loss. Patients with ADHD may have difficulty performing self-care, hurting their oral conditions. They may also consume a high amount of sugar-containing food and beverages and cariogenic foods, contributing to poor oral hygiene. Lastly, xerostomia caused by ADHD medications also contributes to dental caries.7
Poor oral health habits in patients with ADHD, such as lack of tooth brushing, can lead to oral infections and diseases leading to tooth pain and potentially leading to tooth loss, resulting in poor eating behavior and poor nutrition.8
Coronary Heart Disease
Patients with ADHD are potentially at risk of developing coronary heart disease since dental caries and periodontal disease are hypothesized to contribute to a pro-inflammatory state, accelerating the atherosclerotic process and leading to coronary heart disease.9
Implications for Dental Practice for Patients With ADHD
Each patient with ADHD needs to be evaluated individually to develop a dental treatment plan since no one plan works for all patients. Different factors such as the financial situation of the patient, access to care, and other medical problems need to be considered when developing a treatment plan.
Furthermore, patients with ADHD can be restless, fidgety, or have difficulty sitting in one place for an extended period, which can be challenging in dental settings and interfere with treatment. The following implications for treating dental patients with ADHD are important to keep in mind.
Patients with ADHD usually take medications to treat their disorder. It is important to keep track of the medicines. Stimulants are usually given as treatment for ADHD, and their effects are commonly experienced within 30 to 60 minutes of taking them. So, clinicians will want to ensure that sufficient time has elapsed between taking the medication and the dental appointment.
Moreover, knowing the type of medications the patient is on is essential since short-acting stimulants can interfere with dental appointments if the dosage does not cover the dental appointment time. Obtaining a patient’s medical history, including the use of illicit substances, is crucial when treating adult patients with ADHD to minimize the risk of substance abuse.
Setting the Stage
Patients with ADHD, especially children, do best when they know what to expect during a dental appointment. So, it is essential to communicate with the patient and inform them of what will occur. For children, communication should be done according to the child’s developmental level so that they understand and remain comfortable during the appointment.
Furthermore, discussing incentives that the child can earn if they properly sit through the appointment can help make the experience easier.
Inattention and a short attention span are characteristics of ADHD. So, instructions for a dental appointment should be issued one at a time to patients with ADHD to avoid distraction and forgetting the instructions. Furthermore, instructions to be followed after leaving the dentist’s office should be written down carefully since patients with ADHD are often forgetful and disorganized.
Mornings are a good time to schedule dental appointments when patients with ADHD are less tired, more attentive, and better able to remain seated in the dental chair. Moreover, most medication regimens are designed for the maximum drug effect to occur during the early part of the day, making morning appointments more appropriate.
Dental professionals should try to make appointments as short as possible since patients with ADHD have trouble sitting still for extended periods. The wait times between patients should also be minimized.
Positive reinforcement can be useful in obtaining compliance from a child with ADHD during appointments. Positive reinforcement can be given in the form of praise or tangible rewards such as stickers or temporary tattoos. Positive reinforcement comes from the basic behavioral theory that rewarded behaviors will increase in frequency. That is, praising or rewarding a child when they do well will make them more likely to continue good behavior.
The Tell-Show-Do method of behavior has shown value in managing children with ADHD and can be used when introducing new procedures. For example, if dental professionals want children to learn the correct tooth brushing method, they can first tell the child how to do it, then have the child watch them do it, and then allow the child to do it themselves.
Breaks are important when working with patients with ADHD, even if they are brief. During the break, the clinician can let the patient get out of the dental chair, if possible. Breaks can also be used to let the patient know what will happen during the rest of the appointment or how much longer a procedure will take.
Use of Dental Sedation
Dental sedation may be necessary if patients with ADHD need dental work done and cannot cooperate with the dentist. Dental sedation can safely and effectively manage behavior during treatment. There are several options for dental sedation:
- Inhaled minimal sedation – This method involves the patient breathing in nitrous oxide. This mild sedative agent can help the patient relax and safely manage pain and anxiety during dental treatment.
- Oral sedation – This method is the most common in sedation dentistry. During this method, the patient is given a pill to swallow, which can either be mild, making them drowsy, or moderate, making them fall asleep.
- IV moderate sedation – With this method, the sedative drug is given intravenously. This method works quickly, and the dentist can continually adjust the sedation levels.
- Deep sedation – Deep sedation or general anesthesia will make the patient nearly or totally unconscious. With general anesthesia, the patient cannot wake up until the effects wear off or are reversed.
ADHD Medications That May Affect the Oral Health of Patients
ADHD medications come with potential dental-related side effects:
|Generalized||amphetamine||xerostomia, dysgeusia, bruxism|
|Hyperactivity||antihypertensive (clonidine, guanfacine)||dysgeusia, sialadenitis dysphagia, xerostomia|
|Repetitive Behavior||mood stabilizers (bupropion, imipramine)||bruxism, glossitis, stomatitis, gingivitis, dysphagia, dysgeusia, sialadenitis, xerostomia, discolored tongue, oral edema|
Dental Treatment and Prevention
The prevention of oral conditions is essential in managing the dental health of patients with ADHD. Children and adults with ADHD should follow a more frequent dental appointment schedule. Furthermore, parents and caregivers of children with ADHD should support them in maintaining healthy daily oral habits such as tooth brushing along with healthy food and drink consumption. Dental professionals usually follow these guidelines for better treatment and prevention:
- Carefully monitor caries development, bruxism, onset and progression of periodontal disease, and dental or oral trauma.
- Help patients form good oral habits and reinforce oral hygiene.
- Switch to prescription toothpaste. Patients with higher cavity risk may benefit from prescription toothpaste.
- Discourage consumption of sugary foods and beverages.
- If the patient has xerostomia:
- Educate them on proper oral hygiene and nutrition.
- Recommend brushing teeth with a fluoride-containing dentifrice before bedtime.
- Recommend lozenges, mints, or gum to stimulate the production of saliva and caries resistance.
The behavior of adults with ADHD in the dental office is usually not significantly different from that of adults without ADHD. So, usually, only minimal modification is required to provide comprehensive dental care to adults with ADHD. However, treating children with ADHD can be challenging. A dentist can run an appointment smoothly for a child with ADHD when they:
- Understand their patient’s needs
- Have a non-judgmental and positive attitude
- Stay composed and patient
- Express empathy and praise
- Speak directly
Dental Care Tips for Parents of Children With ADHD
Below are some tips for parents and caregivers of children with ADHD:
- Take a tour of the dental office before the appointment to familiarize the child with the office and appointment routine to minimize anxiety levels.
- Talk to the child about visiting the dental office in a positive tone.
- Repeat instructions multiple times.
- Use highly stimulating educational material such as pictures or books of the dental office or appointment routine so that the child can visualize what will happen.
- Discuss techniques with dentists on how to create a successful dental visit.
- Maintain a tooth brushing schedule.
- Emphasize regular brushing. The brushing technique will eventually become better with time.
- Be patient with the child and understand that instilling an oral hygiene routine may take time and will probably involve trial and error to find a technique that works best.
- Provide them with anticipatory guidance on how to prevent and manage dental injuries.
Finding the Right Dentist for Patients With ADHD
Finding the right dentist is essential for the oral health of patients with ADHD. Visiting the dentist regularly is important, so it is crucial to find someone who is a good fit, especially for children with ADHD. Patients with ADHD and parents of children with ADHD can ask their dentist numerous questions to help them decide if they are a good fit. Here are some great questions to ask.
Do you have experience working with patients with ADHD?
Ask the dentist if they have any experience working with patients with ADHD since dentists with previous experience will know how to deal with patients with ADHD. Furthermore, dentists with this expertise will be more comfortable ensuring that the dental visit runs smoothly.
Are you comfortable working with patients with ADHD?
Patients with ADHD require special attention during dental visits. Ask around for a referral to a dentist who specializes in special needs care. Dentists with this expertise can better accommodate the needs of patients with ADHD.
Can any special accommodations be made for my child with ADHD?
Suitable dentists should be ready to cater to any special accommodations. It is especially important that children with ADHD feel as comfortable as possible during dental appointments, so accommodations like asking whether you can stay with them throughout their appointment can be requested.
Moreover, you can also ask the dentist if they can reduce the wait time between appointments to keep your child from getting fidgety or hyperactive in the waiting room. Small adjustments like these can make a huge difference in a child’s dental experience.
Patients with ADHD, especially children, are more susceptible to oral diseases such as dental caries due to poor oral hygiene practices. So, regular dental appointments are needed, with extra attention paid to preventive dental care.
Children with ADHD also require support from their parents or caregivers through frequent monitoring of tooth brushing and healthy food and drink consumption to maintain their oral health status.
The right dentist will not misinterpret inattention, restlessness, missed appointments, and inability to complete home-care tasks as non-compliance but will view them as signs of ADHD that require compassion, understanding, and implementation of special management techniques.
About the Author
Dr. Greg Grillo, DDS, studied at the University of Washington, where he received a bachelor’s degree with Honors and later attended dental school on the same campus. Following dental school, Dr. Greg served in the United States Navy as a dental officer. During this time, he received advanced training in specialty areas of dentistry while also treating families of members of the military.
As well as sharing valuable information on dentistry and oral health, Dr. Greg remains a practicing dentist to this day. He works with families in the Okanogan Valley, where he lives with his wife and three children.
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