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FACT SHEET: Attention Deficit Hyperactivity Disorder (also known as “ADHD” and “hyperkinetic disorder”)

Date of Publication: January 31, 2019
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Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No, unless the patient/client displays behavioural signs/symptoms that pose a risk to himself/herself or the dental hygienist during procedures (e.g., extreme restlessness or impulsivity).

Is medical consult advised?

  • No, if ADHD has been previously diagnosed and is well controlled. 
  • Yes, if ADHD is newly suspected or poor control of previously diagnosed ADHD is suspected.
  • Yes, if severe xerostomia is suspected to be related to medication used to manage ADHD (which may improve if an alternative drug is a consideration).

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • No, unless the patient/client displays behavioural signs/symptoms that pose a risk to himself/herself or the dental hygienist during procedures (e.g., extreme restlessness or impulsivity).

Is medical consult advised? 

  • See above.

Is medical clearance required? 

  • No, unless severe leukopenia (i.e., reduced white blood cell count, and hence immunosuppression) is suspected with antidepressant or antipsychotic medication use. [This would be a rare situation in the dental hygiene office setting.] 

Is antibiotic prophylaxis required?  

  • No (in the absence of immunosuppression).

Is postponing treatment advised?

  • No, unless:
    • medical clearance is pending regarding possible immunosuppression associated with antidepressant or antipsychotic use; or 
    • the patient/client exhibits behavioural signs/symptoms that may pose a risk during, or cause inability to perform, procedures, in which case medical treatment is first needed.

Oral management implications

  • Dental hygienists are likely to encounter children and adolescents with ADHD. Poor tooth-brushing and frequent snacking habits are more frequent in affected patients/clients. In particular, children with ADHD tend to brush their teeth for a shorter duration than children without ADHD and are more likely to have a history of assisted brushing1. 
  • Children with ADHD require rigorous preventive oral care, especially during adolescence. This will help address the tendencies for poorer oral hygiene and oral health behaviours.
  • Behavioural management challenges may be posed by patients/clients, which in turn affect treatment strategies. Parents of children with ADHD may be more likely to perceive that their children dislike visits to oral health professionals than do parents of non-ADHD children. 
  • Short morning appointments are generally recommended. Fatigue may be experienced later in the day, compounded by possible wearing off of medication — this makes it more difficult for the patient/client to sit through the appointment and listen to instructions.
  • When treating children with ADHD, distractions in the office should be limited. To reduce distractibility of the patient/client, music via earbuds or television can be utilized. It is also advisable to succinctly discuss with the child what the appointment will involve to avoid surprises.
  • The dental hygienist should use a neutral, monotone voice, particularly when giving oral care instructions. Fluctuations in tone and volume may distract patients/clients with ADHD, and they might interpret different tones as having unintended meanings, such as annoyance from the hygienist. 
  • Instructions should be given one at a time, with allowance of several seconds for the patient/client to process the information. Eye contact should be maintained to keep the patient/client’s attention. 
  • Children with ADHD respond well to positive reinforcement, and hence giving praise for following instructions and for at-home health care routine is important. By working collaboratively with the child’s parents, a similar system of rewards can be put in place at home and as an adjunct to optimize behaviour in the dental hygiene office. 
  • Medications used to treat ADHD can increase blood pressure (BP) and heart rate. Therefore, vasoconstrictors
    (e.g., epinephrine) should be carefully evaluated for local anaesthesia and administered only in low doses2. BP and heart rate should be monitored closely throughout dental procedures requiring vasoconstrictors in conjunction with local anaesthetics. At the same time, it is important to achieve profound anaesthesia during dental procedures to avoid endogenous epinephrine reacting with the patient/client’s medication.
  • Narcotic-containing analgesics (especially meperidine) should be avoided peri- and post-operatively in patients/clients taking amphetamine or dextroamphetamine. Concomitant use can cause hypotension, respiratory syndrome, and/or serotonin syndrome3. 
  • Certain antibiotics, including quinolones (e.g., ciprofloxacin, levofloxacin, and moxifloxacin) and macrolides
    (e.g., erythromycin and azithromycin) can cause cardiac dysrhythmias in patients/clients taking amphetamine or dextroamphetamine. Therefore, medical advice is recommended to inform prescribing by dentists in patients/clients with ADHD. 
  • Oral sedation can be difficult to achieve safely, because ADHD medications affect the central nervous system. While inhalational sedation with nitrous oxide-oxygen may be the safest modality, medical advice should be sought beforehand. 
  • Adequate aspiration should be ensured to decrease the possibility of increasing the stimulant effect of ADHD medication. 
  • Medicated children with ADHD may cope better with effective tooth brushing than non-medicated children. 
  • An electric toothbrush with a timer can promote brushing for a full 2 minutes. 
  • Oral health behaviours in adolescents with ADHD may be instrumental in shaping their future dental needs.

Oral manifestations

  • The dental literature is inconclusive and contradictory about the oral manifestations of ADHD and its associated factors. Some studies, but not all, have found increased prevalence and/or extent of caries, periodontal disease, plaque, tooth wear, dental (and orofacial) trauma, and/or lower unstimulated salivary flow. When incipient enamel caries is included, some studies have reported significantly higher caries prevalence in older adolescents with ADHD.
  • Higher rates of gingivitis and bruxism tend to be found in patients/clients with ADHD.
  • Xerostomia4, gingival enlargement, bruxism, stomatitis, dysgeusia, edema and/or discolouration of the tongue, and glossitis are side effects of medications5 used to treat ADHD. 
  • Smoking rates are elevated in affected adults, leading to increased risk of oral cancer.

Related signs and symptoms

  • ADHD is a childhood-onset neurodevelopmental disorder that involves a pattern of inattention, impulsivity, and hyperactivity lasting more than 6 months, which is associated with significant functional impairment. While the underlying definitive causes of ADHD are unknown, there are likely genetic contributors as well as non-genetic factors, the latter posited to include premature birth, exposure to high levels of lead in early childhood, brain injuries, and maternal use of alcohol or tobacco. 
  • ADHD is one of the most common chronic health conditions affecting school-age children, with a prevalence of 3% to 7% in children under the age of 18 years. Males are 3 times more likely to be affected, although ADHD may be misdiagnosed in females due to differing manifestations6. 
  • Types of ADHD include:
    • combined type, with both inattention and hyperactivity signs/symptoms (which affects the majority of children with ADHD); 
    • predominately inattentive type; and
    • predominately hyperactive-impulsive type.
  • Symptoms typically start between the ages of 3 and 5 years but are usually most prominent in the elementary school grades. In children, some impairment must be shown in at least two settings (e.g., school and home). About 75% of patients/clients will continue to have the diagnosis through adolescence, and over half of cases continue into adulthood. Severity of childhood ADHD tends to predict adult ADHD. For an adolescent or adult to receive a diagnosis of ADHD, some hyperactive-impulsive symptoms need to have been present prior to age 12 years. 
  • Symptoms of inattention include: often pays little attention to details or makes careless mistakes in school/work; has difficulty staying attentive in tasks or activities; seems not to listen when spoken to directly; fails to finish a task or follow through on instructions; often has difficulty organizing tasks and activities; avoids, dislikes, or is reluctant to undertake tasks that require sustained effort (e.g., school work and homework); often misplaces things that are required for tasks or activities; is easily distracted by external stimuli; and is often forgetful in daily activities. 
  • Symptoms of hyperactivity or impulsivity include: often fidgets or squirms; often leaves seat when remaining seated is expected; often runs around in inappropriate situations; has difficulty playing quietly; is often “on the go”; often talks excessively; often blurts out answers to questions that have not been completed; has difficulty waiting one’s turn or delaying gratification; and often interrupts or intrudes on others. In adults, hyperactivity may manifest as extreme restlessness and/or wearing out others with constant activity, and impulsivity may manifest as making hasty actions or decisions (which may have high potential for harm) without thinking about the consequences.
  • Gross and fine motor abilities development may be slightly impaired in some patients/clients. 
  • Traumatic injuries tend to be more common in children with ADHD, which may be linked to functional impairments that affect motor coordination (and hence increase risk of falls and collisions) and peer relationships as well as increased physical abuse. 
  • The severity of ADHD tends to increase during adolescence, which is thought to be related to greater responsibilities and reduced supervision. Significant impairment occurs in social, academic, and/or occupational functioning, including difficulties in relationships with family and friends. 
  • Symptoms of ADHD can change over time as a patient/client ages. In young children, hyperactivity and impulsivity tend to predominate, whereas inattention tends to become more prominent as children reach elementary school. Restlessness, fidgeting, difficulties with relationships, and antisocial behaviours are common in adolescence, with restlessness, inattention, and impulsivity tending to persist into adulthood. 
  • Co-morbidities are common, including learning disabilities, conduct disorder, anxiety disorder, depression, bipolar disorder, obsessive compulsive disorder, and substance abuse.

References and sources of more detailed information


Date: February 5, 2018
Revised: March 30, 2023


FOOTNOTES

1 In younger children with ADHD, the effects of shorter brushing times may be mitigated by increased frequency of parental-assisted tooth brushing. As children reach adolescence, the impact of irregular tooth brushing in the absence of assistance may be more likely to manifest as caries.
2 Local anaesthetics containing levonordefrin should not be used in patients/clients taking atomoxetine (a norepinephrine reuptake inhibitor), because the combination can increase blood pressure and cause cardiac dysrhythmias.
3 Serotonin syndrome (SS) occurs when medications are taken that cause high levels of the chemical serotonin to accumulate in the body.  Signs/symptoms include: agitation, restlessness, confusion, elevated heart rate and blood pressure, dilated pupils, muscle twitching or rigidity, reduced muscle coordination, sweating, diarrhea, headache, and shivering. In severe, life-threatening SS, signs/symptoms are high fever, seizures, cardiac dysrhythmias, and unconsciousness.
4 Stimulant drugs (such as methylphenidate, dextroamphetamine, pemoline, and amphetamine salts) used to treat ADHD may cause dry mouth, as well as affect acidity and levels of bacteria in the mouth. These effects may increase risk of caries.
5 Drugs prescribed to manage ADHD fall into two main categories: psychostimulants and non-stimulants. Stimulants (such as amphetamine, dextroamphetamine, methylphenidate, and dexmethylphenidate) increase the availability of dopamine and norepinephrine in the brain, which improves the patient/client’s alertness and attention span, as well as reduces hyperactivity. Non-stimulants (such as atomoxetine) affect norepinephrine levels but have no effect on dopamine levels. The most effective treatment for ADHD is usually a combination of medication with behavioural therapy, psychotherapy, and/or emotional counselling. Parents may also be encouraged to participate in skills training to learn techniques for managing their child’s behaviour. Antidepressants are sometimes used in the management of ADHD, as are antipsychotic drugs (e.g., risperidone, olanzapine, and quetiapine) and alpha-agonist hypotensive agents (e.g., clonidine). Depending on the age of the patient/client and the manifestations of ADHD, a paediatrician, psychiatrist, and/or psychologist may be involved in care.
6 Female children with ADHD are more likely to have problems with inattention than with hyperactivity.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.