Attention-deficit/hyperactivity disorder

Overview

Board takeaway: Assess the child’s actual caries risk, cardiovascular status, and drug interactions.

Attention, impulsivity, daily routines, and medication effects can influence trauma risk, home care, and cooperation.

How does Attention-deficit/hyperactivity disorder affect dental management?

• Timing: ask the family when attention and medication effects best support a visit.
• Medication schedule: Confirm usual dosing and any prescriber-directed medication breaks; neither the diagnosis nor a medication holiday automatically rules out treatment
• Communication: Tell-show-do, ask-tell-ask, positive reinforcement, distraction
• Local anesthesia: stimulants raise heart rate and blood pressure. Aspirate, inject slowly, keep epinephrine within its dose limit, and remain within the weight-based local anesthetic maximum.
• Sedation: Check for interactions and airway issues before oral sedation; stimulants can interact with sedatives
• Prevention: supported brushing routines, fluoride toothpaste, and recall and varnish based on caries risk. Consider sugar-free saliva stimulation when developmentally appropriate and mouthguards for sport

Guanfacine prescribing information.

Exam pearl

What is Attention-deficit/hyperactivity disorder?

A neurodevelopmental disorder involving persistent inattention and/or hyperactivity and impulsivity that are inappropriate for developmental level and interfere with daily functioning.

What are the main systemic features of Attention-deficit/hyperactivity disorder?

• Presentation: Inattentive, hyperactive-impulsive, or combined presentation; about 10% of US children
• Diagnosis: Boys more often diagnosed; inattentive type more common in girls
• Comorbidity: Comorbid learning disability, anxiety, ODD or conduct disorder, autism, sleep-disordered breathing
• Medications: stimulants (methylphenidate, amphetamines), nonstimulants (atomoxetine), alpha-2 agonists (guanfacine, clonidine)

What oral findings occur in Attention-deficit/hyperactivity disorder?

• Trauma: Impulsivity and coordination or attention difficulties can increase risk of orofacial trauma; the magnitude varies among studies
• Caries: Caries risk can rise with inconsistent brushing, frequent snacks, and medication-related dry mouth; assess these factors rather than assigning risk from the diagnosis
• Habits: Bruxism, nail biting and attrition may occur; these findings are not diagnostic of ADHD
• Stimulant side effects: xerostomia, bruxism, reduced appetite

For Attention-deficit/hyperactivity disorder, what do you check before oral sedation?

• Drug-specific review: check stimulants and alpha-2 agonists (clonidine or guanfacine) separately.
• Guanfacine effects: Guanfacine can cause hypotension and bradycardia and can add to the sedative effects of CNS depressants. Guanfacine prescribing information.
• Airway and setting: assess comorbid sleep-disordered breathing and whether the child will tolerate the setting
• AAPD sedation guidance: appropriate monitoring and personnel

Sources

• Supplemental study guide: Pediatric Dental Study Guide: Attention Deficit Hyperactivity Disorder (ADHD)
• Policy Prevention of Sports-Related Orofacial Injuries
• Behavior Guidance for the Pediatric Dental Patient
• Molar-Incisor Hypomineralization
• AAPD best practice: AAPD: Management of Dental Patients with Special Health Care Needs (2026)