Pediatric Dental Health

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Children With ADHD
Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood, affecting 6 percent of school-age children. The clinical hallmarks of this genetically influenced, neuropsychiatric disorder are inattention, hyperactivity, and impulsivity. ADHD is often accompanied by other disorders such as learning disability, oppositional defiant disorder, anxiety, or depression. Children with ADHD usually have difficulty functioning at home and at school, and with peers.

The symptoms of ADHD include inattention, hyperactivity, and impulsivity. Inattentive children are disorganized and easily distracted. They have a hard time keeping their mind on a task, and get bored quickly. Hyperactive children are always in motion. They can't sit still, and they touch everything. Impulsive children have difficulty waiting for things. They may grab a toy from another child, or may hit another child when they are upset.

Although children can show signs of ADHD at an early age, a diagnosis is usually not made until they start school. This is because the symptoms may be more apparent in the classroom. The diagnosis of ADHD can be made by using well-tested diagnostic interview methods. Diagnosis is based on history and observable behaviors in the child's usual settings. There is no single test for ADHD. The diagnostic evaluation starts when the child's pediatrician takes a complete health history to rule out physical problems. The pediatrician will also ask about the child's behavior at home and in school.

The most effective treatment for ADHD is a combination of medication, behavior-changing therapy, and environmental modifications.

ADHD is one of the best researched disorders in medicine. Despite progress in the assessment, diagnosis, and treatment of ADHD, the disorder and its treatment have remained controversial. The main controversy continues to be the use of psychostimulants for treatment. It may seem strange to give stimulants to a child with hyperactivity, but these drugs actually reduce hyperactivity and increase the attention span of the child. These medications do not cure the disorder, but they do control the symptoms temporarily. For school-age children with ADHD, the most common medication taken is Ritalin (methylphenidate hydrochloride). This medication is not addictive, but may have side effects, depending on the dose. The side effects associated with a moderate dose may include decreased appetite, and insomnia. The usual dose of Ritalin is 5 to 20 MG, given two to three times per day. There is no conclusive evidence that careful therapeutic use of Ritalin is harmful to a child with ADHD.

Behavior-changing therapy includes contingency management techniques. Examples of contingency management in the classroom setting are the point/token reward, time-out, and response cost techniques. A combined medication and behavioral treatment protocol results in improved social skills. An important potential advantage for including behavioral treatment is the possibility of improving social function with a reduced dose of stimulants.

Environmental modifications in the classroom may include: posting clear rules with rewards for appropriate behavior, providing a place to sit that has few distractions, and providing an area where the child can move around and release excess energy.

A recent study found a correlation between reduced activity in the basal ganglia region of the brain, called the putamen, and ADHD hyperactivity. By using a new diagnostic tool called T2 relaxometry, the blood flow to the basal ganglia can be measured, and this may improve the diagnosis and treatment of ADHD.
Teicher MH, et al: Functional deficits in basal ganglia of children with attention-deficit/hyperactivity disorder shown with functional magnetic resonance imagery relaxometry. Nature Medicine. Vol 6 Number 4 pp 470-473. April 2000.

Teething In Babies
Teething has been the subject of myths and controversy for centuries. In the 4th century B.C., Hippocrates said that "teething infants suffer from itching of the gums, fever, convulsions, diarrhea, especially when they cut their eye teeth." Up through the end of the nineteenth century, teething was considered a leading cause of childhood death. During that century, the "treatment" for teething included leeches, emetics, mercury-based teething powders, and "lancing" of the gingiva. In many cases, deaths of children were actually due to the remedy, and not to teething! As late as 1954, a theory of "reflex stimulation" was cited to explain the prevailing dogma on teething.

Today, parents still attribute many infant symptoms to teething. They incorrectly believe that teething causes fever, pain, irritability, sleep disturbance, biting, drooling, rashes, ear pulling, feeding problems, runny nose, loose stools, and infections. The truth is that many symptoms previously thought to be associated with teething are simply coincidental findings!

The eruption of baby teeth begins when other changes in an infant's immune system, growth, and development are also occurring. The eruption of the primary teeth usually begins around 6 months of age. This is, coincidentally, when infants have lost most of their maternally-derived antibody protection. By the age of 6 months, the number of maternal antibodies has decreased to a very low level, predisposing an infant to a variety of infections. Drooling in infants reaches its maximum level just before tooth eruption. This is because in early infancy, the ability to swallow all of the saliva is not yet well-developed. Putting objects in the mouth, and biting them, also first occurs at the time of teething. This newly-acquired ability to "mouth" objects is simply part of the normal neurological development of a child.

Parents should always seek the advice of a physician when their child has an illness which occurs simultaneously with teething. This will permit the physician to rule out any serious medical problems. Parent should remember that infants with oral Herpes Simplex Virus-1 may be misdiagnosed as having teething problems.

What can be done about the pain associated with teething?

Have two clean teething rings, which have been chilled, ready for baby chew on.
Give children's Tylenol elixer, as needed, to alleviate pain and inflammation.
Note that using benzocaine ointment on baby's gums may not be a good idea because:
Benzocaine ointment may sensitize your baby to future benzocaine-related allergic reactions.
Benzocaine ointment may cause numbing of the throat, and your baby may choke if too much is used.

One medical journal recently published a study on teething. A prospective study was conducted on healthy infants to determine which symptoms might be attributed to teething, and to predict the eruption of primary teeth based on an infant's symptoms. The study concluded that many mild symptoms previously associated with teething were found to be only coincidental, and not significantly associated with dental eruption.
Macknin ML, Piedmonte M, Jacobs J, Skibinski C: Symptoms associated with infant teething: a prospective study. Pediatrics 2000 April; 105(4):747-752

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