Oral Health and Behavior in Children with Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a common developmental disorder and has a substantial impact on many situations in the child’s daily life. The present thesis investigates the behavior of children with ADHD in a dental setting—that is, behavior management problems (BMP), interaction between child and dentist, dental anxiety, and stress—and the oral health of these children compared to a control group. The specific aims of this thesis were to test the hypotheses that children with ADHD display more BMP during dental treatment, display more problems in the interaction process with the dentist, exhibit a higher degree of dental anxiety, have a different stress reaction (measured as salivary cortisol) during a dental recall visit and a different diurnal cortisol variation, have a higher prevalence of caries and gingivitis, and have poorer oral health behavior than children in a control group. All children born in 1991 (n=555) in one Swedish municipality were screened for behavior, attention, and learning problems with Conner’s 10-item questionnaire and a questionnaire focused on executive and learning problems. Thirty-five children fulfilled the criteria for ADHD and were classified according to whether they had ADHD of the combined, inattentive, or hyperactive-impulsive type. Children with no behavior, attention, and learning problems from the same population constituted a control group. In the first study, dental records of the subjects were obtained and data regarding notes on BMP between 3 and 10 yr of age were compiled. The children underwent a clinical dental examination at age 11 yr, and bite-wing radiographs were taken. The parents completed the Dental Subscale of Children’s Fear Survey Schedule (CFSS-DS). In the ADHD group, the prevalence of BMP increased between age 7 and 9 yr. A significant difference between the groups was found at age 8. Compared to controls, children with ADHD had a significantly higher number of decayed, missing, or filled surfaces (DMFS, 1.0 ± 1.5 vs 2.0 ± 3.0, P = 0.032) and decayed surfaces (DS, 0.5 ± 0.9 vs 1.7 ± 3.6, P = 0.016). Differences between the groups in CFSS-DS scores were nonsignificant. In the second study, the dental recall visit at age 11 was recorded on video and analyzed in detail. Interaction between the dentist and the child was scored as verbal and nonverbal initiatives and responses. Compared to the children in the control group, the children with ADHD made significantly more initiatives, especially initiatives that did not focus on the examination or the dentist. The children with ADHD made fewer verbal responses and had more missing responses. These problems in communication resulted in less two-way communication between the dentist and the children with ADHD than between the dentist and the children in the control group. In the third study, the children, all age 13, underwent a clinical dental examination and completed two questionnaires on dietary habits and dental hygiene habits. Differences between the groups regarding DMFS, DS, initial caries lesions, and gingival inflammation were nonsignificant. Forty-eight percent in the ADHD group brushed their teeth every evening compared to 82% in the control group. Corresponding frequencies for brushing the teeth every morning were 48% and 75%. Children with ADHD were 1.74 times more likely to eat or drink more than five times a day than children in the control group. In the fourth study, the children, all age 13, underwent a clinical dental examination and completed the Corah Dental Anxiety Scale (CDAS). Four saliva samples were gathered for analysis of cortisol: one before the dental examination, one after, and two the following morning. The subgroup ADHD with hyperactivityimpulsivity had significantly lower cortisol levels than controls 30 min after awakening. When cortisol values were plotted on a timeline, this subgroup always had lower cortisol concentrations than children in the control group. The correlation between CDAS scores and cortisol concentrations before the dental examination was significant in both the ADHD and the control groups. In conclusion, this thesis found that children with ADHD compared to a control group have more dental behavior management problems; exhibit more problems interacting with the dentist, with particular difficulties staying focused on the examination; do not exhibit a higher degree of dental anxiety, except if the child has several symptoms of hyperactivity or impulsivity; have a blunted cortisol reaction, if the child has several symptoms of hyperactivity or impulsivity; have a higher caries prevalence and incidence at age 11, but not statistically significantly higher at age 13; do not have a higher prevalence of gingivitis; and have poorer oral health behavior.