A Practical Approach to Special Care in Dentistry. Группа авторов

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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

      1 What factors may be impacting on this patient's poor oral health and increased caries risk?Compliance issues in daily lifeLack of perceived needCognitive difficulties due to learning disabilityMotor problems due to hyperactivityFigure 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 dietIrregular dental check‐ups due to dental anxiety and lack of accessOral dryness due to methylphenidateChanges in oral health behaviour during adolescence

      2 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 supplementationAcclimatise the patient further – he has already demonstrated improved compliance by allowing bitewing radiographsReattempt an orthopantomogram and consult with an orthodontist as the patient is at a mixed dentition stageIf compliance is limited, plan to allow deciduous teeth to exfoliate if they are asymptomatic and focus on the permanent dentitionPlace fissure sealants and attempt restorations (temporary restorations can be recommended and any local anaesthetics avoided for the patient to get used to)

      3 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 symptomsCapacity of the patient to understand what is plannedIn 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

      4 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 ADHDIt may also be a side‐effect of the medications used to manage the condition, including methylphenidate

      5 What other factors could be contributing to tooth surface loss?Xerostomia due to methylphenidateDietary acid/erosion due to high sugar and acid intake

      6 What factors are considered important