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CHAPTER 9
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BACKGROUND INFORMATION 1
Attention Decit Hyperactivity Disorder
• ADHD is a neurobiological disorder of executive
function. “Executive function” refers to the
mental skills needed to accomplish tasks such
as paying attention, managing time, organizing,
and minimizing impulsive actions
• Symptoms can range from mild to severe.
Diagnostic criteria specify that at least several
symptoms must be present prior to 12 years of age
and cannot be otherwise attributable to another
mental disorder (i.e. depression, bipolar disorder,
anxiety disorder, substance abuse orothers)
Types ofADHD
• Predominantly
inattentive presentation (ADHD‐PI)
• Predominantly hyperactive–impulsive
presentation (ADHD‐PHI)
• Combined presentation (inattentive and
hyperactive–impulsive) (ADHD‐C)
Examples ofinattention
• Fails to pay attention to details
• Fails to follow through on instructions; fails to
finish school work
• Has trouble getting organized
• Avoids tasks that require sustained focus
• Forgets and/or loses things frequently
• Easily distracted
FUNDAMENTAL POINT 1
Comorbidities Associated withADHD
(Estimated Prevalence)
• Oppositional deant disorder (40–50%)
• Anxiety (20–40%)
• Conduct disorder (7–20%)
• Depression (5–40%)
• Bipolar disorder (10–22%)
• Substance abuse
• Sleep disturbances
(Faraone and Kunwar 2007; Garner et al. 2013)
A
C
E
B
D
Examples ofhyperactivity andimpulsivity
• Fidgeting, squirming
• Runs, climbs excessively
• Talks excessively
• Trouble waiting, taking turns
• Interrupts, intrudes on others
• Always “on the go”
(American Psychiatric Association 2013)
H. Intraoral Exam (Figure9.3.2)
• Anterior and bilateral posterior crossbites
• Class III malocclusion
• Anterior open bite
• Moderate crowding of maxillary arch with ectopic
eruption of maxillary canines
• Moderate plaque deposits throughout mouth
• Marginal gingivitis secondary to poor oral hygiene
• No caries noted
366 Clinical Cases inPediatric Dentistry
Figure 9.3.2 (A–E) Intraoral photographs showing malocclusion and gingivitis.
I. Diagnostic Tools
• Bitewing radiographs were attempted, but patient had
a very strong gag reflex. After several attempts,
patient started to become agitated. Since no caries
were noted on clinical exam, it was decided not to
pursue additional behavioral techniques to obtain
radiographs. Patient may respond well to nitrous
oxide to obtain radiographs at a future visit
J. Differential Diagnosis
• Not applicable
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PATiEnTs wiTHDisAbiliTiEs
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K. Diagnosis andProblem List
Diagnosis
• ADHD
• Asthma
• Eczema
• Class III malocclusion
• Anterior open bite, crossbite
• Moderate maxillary crowding; ectopic eruption of
maxillary canines
• Gingival inflammation
• Xerostomia
Problem List
• Poor oral hygiene
• Strong gag reflex
• Difficulty concentrating on tasks such as
toothbrushing
• Dry mouth contributing to plaque accumulation
L. Comprehensive Treatment Plan
• Establish dental home
• Dental prophylaxis
• Fluoride treatment
• Consider chlorhexidine to help reduce gingival
inflammation
• Review of oral hygiene; work with mother to establish
techniques to either improve child’s ability to brush
more effectively or that may allow mother to assist
• Orthodontic consultation
• Three‐month recall:
Re‐evaluate oral hygiene and gingival status
M. Prognosis andDiscussion
• Up to now, patient has not been performing adequate
oral hygiene on a daily basis. Although she does not
have caries, gingival inflammation is present. Key to
success in this area is finding techniques that will
improve her focus and stop her usual “rushing” to
complete the task. Techniques discussed with mother
include using a timer or short video that the patient
likes that can also act as a “timer”
Discuss with physician possibility of changing medication
•
or dosage to reduce xerostomia (Bimstein etal. 2008)
• Patient sat in chair willingly; verbal and well‐related.
Had difficulty with radiographs due to gag reflex and
inattention. Need to consider behavioral guidance
measures such as very short appointments, very
clearly defined steps and goals, and counting to 10 for
individual steps, such as dental exam (Klingberg 2014)
•
Patient has orthodontic needs. There are several key
considerations in this area:
Patient’s ability to maintain oral hygiene if
orthodontic appliances are placed
Patient’s ability to tolerate intraoral procedures
(strong gag reflex). Further behavioral evaluation will
be made when the patient returns for recall visit
N. Complications andAlternative Treatment
• If patient had clinically visible caries, what behavioral
management techniques could be considered to allow
completion of the radiographic examination and
restorative treatment?
FUNDAMENTAL POINT 2
Medications Frequently Used toManage ADHD
Stimulants
• Methylphenidate (ritalin, Concerta)
• Amphetamine (Adderall, Vyvanse)
Selective Norepinephrine Reuptake
Inhibitor(SNRI)
• Atomoxetine (Strattera)
Alpha2 Adrenergic Agonists
• Guanfacine (Tenex, Intuniv)
• Clonidine (Catapres)
• All of the above medications can cause some
degree of xerostomia. Side effects of the
stimulants include headache, appetite
suppression, sleep disruption, and mood
disturbances. An association between
atomoxetine and increased suicide ideation has
been noted in a small percentage of patients.
While use of stimulants and atomoxetine can
result in blood pressure elevation, the alpha
agonists can cause hypotension, bradycardia,
and sedation.
(Friedlander et al. 2003; Cascade et al. 2010;
Graham et al. 2011)
2
Clinical Cases inPediatric Dentistry 367
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Self‐Study Questions
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PATiEnTs wiTHDisAbiliTiEs
1. What is meant by “executive function?”
2. Is intellectual disability a characteristic
ofADHD?
3. What are the behavioral characteristics of
ADHD‐PHI and how might these behavioral
characteristics affect behavior management in the
dental setting?
4. What classes of medications are used to manage
ADHD? How do these medications affect the
oralcavity?
5. What are some of the comorbidities noted
to occur with ADHD? How might any of these
diagnoses affect oral health care?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 369
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CHAPTER 9
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Self‐Study Answers
1. “Executive function” refers to the mental skills
needed to accomplish tasks such as paying
attention, managing time, organizing, minimizing
impulsive actions
2. Intellectual disability is not a characteristic of
ADHD
3. Examples of ADHD‐PHI include: fidgeting,
squirming, talking excessively, trouble waiting and/
or taking turns, interrupting and/or intruding on
others, always “on the go”. Many of these behaviors
can make providing dental care a challenge.
Consider shorter morning appointments, possible
use of nitrous oxide if patient will tolerate the nasal
apparatus. Also, distractors such as mobile phone
games and videos may be helpful
Bibliography
American Psychiatric Association. 2013. Diagnostic and
Statistical Manual of Mental Disorders (DSM‐5), 5th Edition.
Washington, DC: American Psychiatric Association.
Bimstein E, Wilson J, Guelmann M, Primosch R. 2008. Oral
characteristics of children with attention‐deficit hyperactivity
disorder. Special Care Dent 28(3):107–10.
Cascade E, Kalali AH, Wigal SB. 2010. Real‐world data on atten-
tion deficit hyperactivity disorder medication side effects.
Psychiatry 7(4):13–15.
Faraone SV, Kunwar AR. 2007. ADH in Children with Comorbid
Conditions: Diagnosis, Misdiagnosis, and Keeping Tabs
onBoth. Medscape Psychiatry. https://www.medscape.org/
viewarticle/555748_1 (Accessed 20 June 2019).
4. The classes of medications that are used to
manage ADHD include: stimulants, selective
norepinephrine reuptake inhibitors, alpha2
adrenergic agonists. These medications can cause
some degree of xerostomia
5. Some comorbidities that are associated with
ADHD are: oppositional defiant disorder, anxiety,
conduct disorder, depression, bipolar disorder,
substance abuse, sleep disturbances. These can
interfere with healthy nutrition, a consistent dental
home care routine, and/or follow‐up with regular
dental visits. Medications used to manage some of
these comorbidities can also cause xerostomia
Friedlander AH, Yagiela JA, Paterno VI, Mahler ME. 2003.
The pathophysiology, medical management, and dental
implications of children and young adults having attention
deficit hyperactivity disorder. CDA Journal 31(9):669–78.
Garner AA, O’Connor BC, Narad ME etal. 2013 The relationship
between ADHD symptom dimensions, clinical correlates,
and functional impairments. J Dev Behav Pediatr
34(7):469–77.
Graham J, Banaschewski T, Buitelaar J et al. 2011 European
guidelines on managing adverse effects of medication for
ADHD. Eur Child Adolesc Psych 20:17–37.
Klingberg G. 2014. Children with disabilities. In: Behavior
Management in Dentistry for Children, 2nd Edition. Wright
GZ, Kupietzky A (eds). Hoboken: John Wiley & Sons, Inc.
pp.92–105.
370 Clinical Cases inPediatric Dentistry
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Case 4
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Seizure Disorder, Intellectual Disability
PATiEnTs wiTHDisAbiliTiEs
BA
Figure 9.4.1 (A, B) Facial photographs.
A. Presenting Patient
• Thirteen‐year‐, ten‐month‐old African‐American female
(Figure9.4.1)
• Seizure disorder (epilepsy), cognitive impairment
(severe)
• Visit for dental treatment under intravenous (IV)
sedation
her first seizure at four months of age (see
Background Information 1)
•
Patient’s last seizure was 18 months ago
• Patient did not walk independently until two years,
sixmonths of age
• Patient has never developed age‐appropriate verbal
skills; makes needs and wants known primarily
through body gestures
• According to her neurodevelopmental report, patient
functions at a level of severe intellectual disability
• Current medication: valproic acid (antiepileptic)
E. Medical Consult
• Patient’s primary care physician was consulted prior
to scheduling for IV sedation. According to the
physician, the patient’s seizures are currently well
controlled. No other systemic conditions exist to
contraindicate sedation. Since the patient’s seizures
have been well controlled for more than a year, she is
considered to have either an American Society of
Anesthesiologists (ASA) II or III status, according to
the ASA (see Fundamental Point 1)
B. Chief Complaint
• Patient had maxillary anterior tooth avulsed due to
trauma during a seizure. Patient’s mother would like
this tooth to be replaced
C. Social History
• Patient lives at home with mother, grandmother,
andone younger sister
• Patient attends special education classes in public
school system
D. Medical History
• Patient was born at full term in Antigua
• Patient has history of generalized seizures, tonic/
clonic type. According to mother’s report, patient had
Dental History
F.
• Patient has been treated in current clinic for 10 years,
with annual visits
• Patient has always been extremely resistant to dental
treatment, although she allows her mother to brush
her teeth twice daily
• Due to behavioral resistance, all treatment other than
cursory examination has been accomplished under IV
sedation
• Patient first avulsed her maxillary left permanent
central incisor four years ago. It was reimplanted
within an hour of avulsion and subsequently required
endodontic treatment. The tooth was reavulsed 18
months ago, while the patient was at summer camp,
and the tooth was not reimplanted at that time
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Clinical Cases inPediatric Dentistry 371
CHAPTER 9
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BACKGROUND INFORMATION 1
Seizure Disorders
Denitions
• Seizure: synchronized discharges from a population
of cortical neurons resulting in a clinically evident
alteration of function or behavior
• Epilepsy: two or more seizures not precipitated by
a known cause (i.e. idiopathic seizure activity)
• Of seizure disorders, 70–75% are idiopathic
Nonidiopathic Seizure Etiologies
• Fevers, particularly in children under two years old
• Inborn errors of metabolism
• Congenital brain malformation
• Acquired cortical defect (neoplasm, infection, trauma)
• Neurodegenerative disease
• Neurocutaneous disorders
• A removable appliance (similar to a Hawley) to replace
the missing tooth was fabricated a year ago, but the
patient refused to wear the appliance
• Optimal water fluoridation levels
• Healthy, low‐cariogenic diet
G. Extraoral Exam (Figure9.4.1)
• No significant findings
• Electrolyte imbalances
• Toxins/drugs
Classication ofSeizures
• Generalized (involving both cerebral hemispheres):
Involves loss of consciousness
• Partial (limited to a discrete segment of the
cerebral cortex):
No loss of consciousness; may have altered
consciousness
• Status epilepticus: prolonged, non‐self‐limiting
seizure activity; can be life threatening
• Generalized and partial seizures are subclassified
depending on clinical manifestations
(Turner and Glickman 2005; Lockhart 2013; Engorn
and Flerlage 2015)
• Intact amalgam restorations on the maxillary
andmandibular right permanent first and second
molars
• Occlusion: class I molar and canine relationships,
70% overbite, 1 mm overjet
• Soft tissue within normal limits
• Good oral hygiene
• No active caries noted
H. Intraoral Exam (Figure9.4.2)
• Permanent dentition
• Maxillary left permanent central incisor missing
secondary to trauma
FUNDAMENTAL POINT 1
Obtaining aHistory forSeizure Disorder
• When evaluating a patient with a seizure
disorder, it is important to know if the
seizuresare currently well‐controlled or if the
patient continues to have seizures despite
antiseizure treatment. The following information
should be elicited, either through parental report
or from medical consult (Mehmet etal. 2012;
Lockhart 2013):
Types of seizures
Frequency of seizures
Date of last seizure
372 Clinical Cases inPediatric Dentistry
I. Diagnostic Tools
• Four bitewing radiographs taken while patient was
sedated show no signs of interproximal caries
(Figure9.4.3)
Consciousness and respiratory state of patient
during seizure
If there is any aura, and if so, does it always lead
to a seizure
Physical condition of patient after seizure
Existence of status epilepticus
Antiepileptic medications being taken
• The classication of physical status provided by the ASA
is the most commonly used preoperative risk evaluation
system used in the United States (ASA 2014):
An ASA II patient has mild systemic disease
An ASA III patient has severe systemic disease
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PATiEnTs wiTHDisAbiliTiEs
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BA
D
Figure 9.4.2 (A–E) Intraoral photographs showing missing maxillary left permanent central incisor.
A
B
E
C
FUNDAMENTAL POINT 2
Oral Complications ofSeizure Disorders
• Patients who experience seizures that involve loss
of consciousness and/or loss of motor control are
at higher risk for dental trauma and oral soft tissue
trauma than the general population
C
Figure 9.4.3 (A–D) Preoperative bitewing radiographs.
• A maxillary anterior periapical radiograph was taken
three months prior to this visit and showed no
pathology (not shown)
J. Differential Diagnosis
• Not applicable
D
• Common medications used to manage seizure
disorders can cause signicant complications:
Gingival hypertrophy is often associated with
use of the antiepileptic drug Dilantin (phenytoin).
The gingival hypertrophy can be reduced with
good oral hygiene to remove plaque
Valproic acid can cause decreased platelet
count. Although thrombocytopenia is not
usually severe, planning for significant elective
surgery should include laboratory evaluation of
bleeding parameters
Carbamazepine can cause xerostomia,
glossitis, ulcers, and stomatitis
(Aragon and Burneo 2007; Mehmet et al. 2012)
K. Diagnosis andProblem List
Diagnosis
• Seizure disorder
• Severe cognitive impairment
Problem List
• Maxillary left permanent central incisor missing
secondary to trauma
• Extremely resistant to dental treatment
L. Comprehensive Treatment Plan
• Patient scheduled for two treatment sessions under
IV sedation
• At the first session, the following treatment was
completed:
Thorough oral examination
Radiographic examination
Prophylaxis, topical fluoride treatment
Clinical Cases inPediatric Dentistry 373
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Impressions of the upper and lower arches were
taken so the laboratory could fabricate an
applianceto replace the maxillary left permanent
central incisor
• At the second IV session, the appliance will be
cemented in place
• Unless the patient has problems with the appliance
(or other urgent dental needs), she will be seen under
IV sedation for an annual examination
M. Prognosis andDiscussion
• The prognosis for the appliance to replace the
maxillary left permanent central incisor is
questionable. It is considered a temporary solution
until the patient is old enough for an implant.
Although her seizures seem to be well controlled at
this point, there is greater concern about how the
patient will tolerate the appliance. The patient has
already shown that she will not tolerate a removable
appliance, so it remains to be seen if she will tolerate
the cemented one
• Patient has a mother who is extremely conscientious
about oral care, and motivated to keep her daughter’s
mouth clean. Therefore, her oral hygiene at this time
is excellent. If a time comes when the mother is no
longer the primary caregiver, the prognosis for
continued good oral health is questionable. The
patient’s behavior is difficult, and maintaining her
dentition and periodontium in optimal health will
require a dedicated caregiver
N. Complications andAlternative
TreatmentPlan
• Be aware of the risk for future trauma when planning
treatment in patients who have sustained dental
trauma during a seizure. In this case, it was already
known that the patient would not tolerate a
removable appliance
• The use of a removable appliance in a patient with
uncontrollable seizures is not advised, because it
could become dislodged during the seizure and
causeintraoral soft tissue trauma, or possibly block
the airway
• Likewise, a Maryland bridge was not considered,
because of the possibility of dislodgement and
aspiration during a seizure
• A fixed three‐ (or four‐) unit bridge was not thought to
be appropriate for this patient for several reasons.
First, the remaining maxillary incisors were in excellent
condition, so there was a reluctance to prepare them
for crowns. Second, placing a fixed bridge in this area
would make the abutment teeth more vulnerable, as a
group, to trauma during a futureseizure
• After careful consideration, it was decided that an
implant was the most appropriate long‐term treatment
to replace the maxillary left permanent central incisor
FUNDAMENTAL POINT 3
Emergency Management ofSeizures
• If a patient has a seizure in the dental ofce:
Remove all instruments from patient’s mouth
and away from dental chair
Place dental chair in a supine position as close to
the floor as possible
Place patient on his/her side, if possible
Do not attempt to restrain patient
Time the seizure
Call emergency services if the:
– Caregiver informs you that it is an atypical
seizure
– Seizure lasts longer than three minutes
– Patient becomes cyanotic at any time
374 Clinical Cases inPediatric Dentistry
Administer oxygen at a rate of 6–8 liters/minute
After seizure, try to evaluate patient’s level of
consciousness
Do not allow the patient to leave the office if his/
her level of awareness has not returned to
baseline (this may be difficult to determine in a
patient who has significant cognitive impairment)
Conduct a brief oral examination to determine if
any oral injuries were sustained during seizure
Depending on patient’s post‐ictal status, either
discharge to home with responsible adult or
transfer to emergency room for further
monitoring and evaluation
(Aragon and Burneo 2007)
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Self‐Study Questions
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PATiEnTs wiTHDisAbiliTiEs
1. What are the two main classications for seizure
disorders?
2. What is the denition of epilepsy?
3. What are important questions that need to be
asked before treating a patient with a history of
seizures?
4. The ASA has developed a preanesthesia scale
that attempts to measure what?
5. Do most antiepileptic medications cause gingival
hyperplasia?
6. What other medication can cause oral side
effects, and what are they?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 375
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