2
Cognitive Impairment
2.1 Attention Deficit and Hyperactivity Disorder (ADHD)
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 13‐year‐old male presents to the dental clinic with his mother. She is concerned about her son’s teeth, stating that ‘they are discoloured, and keep falling out’. Other dentists have been unable to examine her son and have refused to provide care.
Medical History
- Attention deficit and hyperactivity disorder (ADHD) diagnosed at the age of 5 years old
- Self‐harm predominantly associated with stress
- Mild learning disability
- Dental anxiety
Medications
- Methylphenidate
Dental History
- Managed to have a single amalgam filling placed in a deciduous tooth when he was 9 years old
- Last dental visit was 18 months ago when repair of a fractured incisal tip was attempted; the tooth is asymptomatic at present
- Mother reports this was a traumatic experience for her son as the dental nurse held her son down to allow the dentist to examine the tooth
- Dentists have since declined to provide care as the patient has refused to co‐operate with examination and treatment
- Now an irregular attender
- Only brushes his teeth once a day or when he remembers and refuses help
Social History
- Lives with parents
- Youngest of five siblings
- Only member of the family with a learning disability and ADHD
- Attends a special education school
- Poor dietary habits, snacks frequently on biscuits and sweets, consumes fizzy drinks daily
Oral Examination
(performed within 2 desensitisation visits)
- Generalised plaque, calculus, gingival inflammation and spontaneous bleeding
- Enamel demineralisation at gingival margins most pronounced on the buccal aspect of the upper teeth
- Fractured incisal tip of tooth #21 – simple without pulp exposure, no mobility (Figure 2.1.1)
- Caries: #54, #53, #65, #75, #84 and #85 (Figures 2.1.2 and 2.1.3)
- Stained fissures: #16 and #26
- Maxillary canine bulge can be palpated buccally on both sides
Radiological Examination
- Patient required acclimatisation appointments to enable bite‐wing radiographs (Figure 2.1.4)
- Hence #54 and #65 present in clinical images but missing in the radiographic images as they had exfoliated naturally by the time the images were taken
- Patient did not accept orthopantomogram, hence further evaluation not possible
Structured Learning
- What factors may be impacting on this patient’s poor oral health and increased caries risk?
- Compliance issues in daily life
- Lack of perceived need
- Cognitive difficulties due to learning disability
- Motor problems due to hyperactivity
Figure 2.1.1 Dentition: generalised plaque, calculus and gingival inflammation, fracture of the incisal tip of tooth # 21.
Figure 2.1.2 Maxilla: caries in teeth #54, #53, #65, stained fissures in #16 and #26.
- Poor oral health habits and diet
- Irregular dental check‐ups due to dental anxiety and lack of access
- Oral dryness due to methylphenidate
- Changes in oral health behaviour during adolescence
- How would you manage the dental caries?
Figure 2.1.3 Mandible: caries in teeth #75, #84 and #85; calculus on the lingual aspect of lower incisors; buccal enamel demineralisation.
- Reduce caries risk – dietary analysis, educate parents, reinforce oral hygiene, consider fluoride supplementation
- Acclimatise the patient further – he has already demonstrated improved compliance by allowing bitewing radiographs
- Reattempt an orthopantomogram and consult with an orthodontist as the patient is at a mixed dentition stage
- If compliance is limited, plan to allow deciduous teeth to exfoliate if they are asymptomatic and focus on the permanent dentition
- Place fissure sealants and attempt restorations (temporary restorations can be recommended and any local anaesthetics avoided for the patient to get used to)
- The patient asks you to repair the fractured incisal tip #21 as he does not like its appearance. What factors would you need to consider?
Figure 2.1.4 Right and left bitewing radiographs: mixed dentition; caries in #75, #84 and #85.
- Further information regarding how and when the fracture occurred, and any related symptoms
- Capacity of the patient to understand what is planned
- In relation to previous successful dental filling placement at the age of 9 years old:
- Where and how it was carried out?
- How co‐operative was the patient?
- What behavioural modification tools were used?
- In relation to unsuccessful treatment a year ago:
- Why was clinical holding used, i.e. was it to assist with uncontrolled movements?
- Was it agreed and consent in place?
- Why did it go wrong?
- With this information, confirm the modified plan
- The patient’s mother has also noticed that her son makes a loud noise with his teeth predominantly at night – what could be the cause and why?
- Sleep and day bruxism has been linked to ADHD
- It may also be a side‐effect of the medications used to manage the condition, including methylphenidate
- What other factors could be contributing to tooth surface loss?
- Xerostomia due to methylphenidate
- Dietary acid/erosion due to high sugar and acid intake
- What factors are considered important in assessing the risk of managing this patient?
- Social
- Irregular attender, dental anxiety
- Learning disability, poor compliance and tolerance
- Self‐injurious behaviour
- Availability of escort
- Medical
- Potential side‐effects associated with methylphenidate include headache or nausea
- Signs of trauma/self‐harm
- Dental
- Bruxism leading to tooth surface loss
- Increased risk of caries due to xerostomia induced by methylphenidate
- High caries rate
- Cariogenic diet
- History of dental trauma
- Social
General Dental Considerations
Oral Findings
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