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Scientific Article PEDIATRIC DENTISTRY V 29 / NO 6 NOV / DEC 07 Scientifi c Article Pharmacologic Behavior Management of Pediatric Dental Patients Diagnosed with AttentionAttention DDefiefi ccitit DisDisorder/Attentionorder/Attention DDefiefi ccitit HHyperactivityyperactivity DisDisorderorder Carolyn A. Kerins, DDS, PhD1 • Alton G. McWhorter, DDS, MS2 • N. Sue Seale, DDS, MSD3 Abstract: Purpose: The purpose of this study was to conduct a survey of Texas pediatric dentists to determine: (1) the percentage of patients they treat with attention defi cit disorder (ADD)/attention defi cit hyperactivity disorder (ADHD); (2) the behavior management techniques that are utilized to treat their patients who suffer from ADD/ADHD; and (3) the relative success rates of these techniques in their practices. Methods: A 17-question, single-answer, multiple choice survey was mailed to 343 Texas pediatric dentists. The mailing list was obtained from American Academy of Pediatric Dentistry and Texas Academy of Pediatric Dentistry member rosters. One mailing was sent, including a self-addressed stamped envelope, for returned responses. Results: A 54% response rate (186 surveys) revealed that nitrous oxide was the most frequently used pharmacologic behavior management technique; however, demerol/promethazine/nitrous oxide was rated as effective most often for treat- ing ADD/ADHD patients. Conclusions: Practitioners believe the incidence of attention defi cit disorder/attention defi cit hyperactivity disorder is increasing, and they are familiar with the medications used to treat the conditions. Texas pediatric dentists are using a variety of sedation techniques and are interested in developing guidelines for sedation of these patients. (Pediatr Dent 2007;29:507-13) Received July 20, 2006 / Revision Accepted FebruaryFebruary 66,, 2002007.7. KEYWORDS: BEHAVIOR MANAGEMENT, ORAL SEDATION, GENERAL ANESTHESIA, ATTENTION DEFICIT DISORDER, ATTENTION DEFICIT HYPERACTIVITY DISORDER Attention defi cit disorder (ADD) and attention defi cit hy- Most children being treated for ADD/ADHD are managed peractivity disorder (ADHD) are considered to be the most with a combination of behavioral and pharmacologic thera- common neurobehavioral disorders among school-age chil- pies. Current drugs employed in the treatment of ADD/ADHD dren. They are estimated to aff ect 3% to 5% of this popula- include: (1) prescription stimulants; and (2) nonstimulants. tion.1 ADD is a diagnosis applied when a patient: (1) persis- The stimulant category includes: (1) methylphenidate (Rit- tently fails to give close attention to details; (2) doesn’t seem alin); (2) dextroamphetamine (Dexadrine); (3) pemoline to listen; and (3) is easily distracted by external stimuli. This (Cylert); (4) amphetamine salts (Adderall); and (5) sus- patient is often referred to as “the daydreamer.” ADHD, on tained-release methylphenidate (Concerta). The stimulant the other hand, is a diagnosis applied to a persistent pattern medications exert their eff ect paradoxically by: of: (1) hyperactivity; (2) impulsivity; and/or (3) inattention. 1. increasing activity in underactive areas of the brain and This person seems to be “always on-the-go.” Boys are 3 to 5 normalizing cerebral blood fl ow and glucose metabo- times more likely than girls to be aff ected. While the nature lism4; or of ADD/ADHD changes as a child reaches adolescence, it is 2. altering the levels of norepinephrine and dopamine.5 estimated that only 20% of children “outgrow” this disor- Recently, nonstimulant medications were introduced der.2 The symptoms of ADD/ADHD are caused by a chemical to treat ADD/ADHD, including atomoxetine (Strattera) and imbalance in the brain, especially in areas controlling con- buproprion (Wellbutrin), which tend to act similarly to anti- centration and impulsive behavior.3 depressants. In 1999, the Multimodal Treatment Study of Children with Attention Defi cit Hyperactivity Disorder—funded by the National Institute of Mental Health—followed nearly 600 school-age children. It found that stimulant medications 3 1Dr. Kerins is assistant professor, 2Dr. McWhorter is professor, and Dr. Seale is were the most eff ective treatment for ADD/ADHD.6 Growing Regents Professor and Chairman, all in the Department of Pediatric Dentistry, Baylor College of Dentistry, Texas A&M University Health Science Center, Dallas, Tex. concerns from the advisory committee of the Food and Drug Correspond with Dr. Kerins at [email protected] Administration, physicians, and parents, however, have re- PHARMACOLOGIC BEHAVIOR MANAGEMENT OF PATIENTS WITH ADHD 507 PEDIATRIC DENTISTRY V 29 / NO 6 NOV / DEC 07 newed interest in behavioral therapy. ADD/ADHD manage- absorption of the midazolam, as methylphenidate inhib- ment includes a balanced treatment plan of pharmacologic its liver microsomal enzymes. Additionally, patients tak- methods combined with behavioral or psychotherapy as well ing methylphenidate may be at risk for prolonged sedation, as environmental manipulation.7 The stimulant medications as most sedative-hypnotic medications are metabolized reduce hyperactivity and improve concentration, while be- in the liver. Thus, if these patients do require higher dos- havior therapy addresses diffi culty with organizational and es of sedation medications, these levels may remain un- social skills.6 Behavior therapy is a structured system of re- usually high even after discharge from the dental offi ce. wards to encourage desired behaviors and consequences to There is little research and scant guidelines to direct the decrease the frequency of undesirable behaviors. Behavior pediatric dental practitioner regarding sedating ADD/ADHD therapy also includes environmental changes designed to patients taking stimulant medications. Consequently, den- minimize distractions. The results of this study indicated that tists have had to “experiment” to determine regimens that stimulants combined with behavior therapy were superior work or fail. These methods may include: (1) altering the for long-term improvement of: (1) anxiety; (2) academic per- dose or discontinuing the dose of stimulant medication prior formance; (3) parent-child relations; and (4) social skills.6 to the dental appointment; (2) administering a stronger dose It has been suggested that “provision of comprehensive or a cocktail of sedation medications; (3) treating these pa- dental treatment to children suff ering from ADHD requires tients in the morning; or (4) scheduling them for treatment modifi cations in the standard regimen.”2 Exactly what these on “drug holidays,” which are usually school breaks. modifi cations are remains unclear. To date, there are no This study’s purpose was to survey Texas pediatric in-depth retrospective and no prospective research studies dentists to determine: (1) the percentage of patients they looking at the eff ect of ADD/ADHD on dental treatment. Be- treat with attention defi cit disorder/attention defi cit cause pediatric dentists typically treat patients from younger hyperactivity disorder; (2) which pharmacologic behavior ages through adolescence, it is likely that they will treat ADD/ management techniques they utilize to treat these patients; ADHD patients. Their treatment presents unique challenges and (3) the relative success rates of these techniques in to the practitioner in terms of pharmacologic and nonphar- their practices. macologic behavior management. Not only does the dentist have to work to gain the child’s trust, but he must also work Methods to focus the patient’s attention throughout the entire dental This study was reviewed by the Institutional Review Board procedure8 either through “tell-show-do”, directive guid- of Baylor College of Dentistry and given “exempt” status. A ance, and/or voice control. multiple-choice survey was sent to 343 pediatric dentists For those children who are unable to be nonpharmaco- (not including pediatric dental residents) in the state of Tex- logically managed in the dental offi ce, pharmacologic mild as. Names and addresses were obtained from the American to moderate sedation may be considered. Ultimately, most Academy of Pediatric Dentistry Web site and from the mail- ADD/ADHD children have a behavior problem but exhibit ing list of the Texas Academy of Pediatric Dentistry. Dentists normal or above-average intelligence. Thus, the reasons for were given approximately 2 weeks to respond to the survey. A sedating this type of patient may be diff erent than those for self-addressed, stamped envelope was included in the mail- treating an anxious patient or one that is too emotionally im- ing. There was neither a second mailing nor any attempt to mature to cooperate. A pediatric dentist may choose to use procure surveys from dentists who did not respond. anti-anxiety drugs such as diazepam or midazolam vs antihis- The survey was composed of 17 questions. The survey’s tamines or opioid analgesics such as meperidine for sedation fi rst section obtained demographic information. The second to avoid perceived drug-drug interactions. As most drugs section surveyed the practitioner’s familiarity with medica- used to treat ADD/ADHD are “stimulant” medications, one tions used to treat ADD/ADHD. A third section inquired about might suspect that the potential for failed sedations exists, as behavioral management techniques the practitioner utilized the 2 treatment regimens appear to “cancel each other out.” to treat ADD/ADHD dental patients. The respondents were Many practitioners have suggested that they experi- instructed to consider their answers based on healthy
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