Key words: Audiovisual distraction eyewear - attention deficit/hyperactivity disorder - dental
anxiety
INTRODUCTION
Attention deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder,
and children diagnosed with ADHD have symptoms such as trouble paying attention, impulsivity,
and hyperactivity.[1 ] Several studies[2 ]
[3 ]
[4 ]
[5 ] reported that pharmacotherapy used to manage symptoms of ADHD alters the salivary
composition and reduces salivary flow, thus increasing the risk of developing dental
caries. Moreover, routine oral care is less common among these children. An often
parent-child conflict also influences oral health behavior. Furthermore, exposure
to high carbohydrate foods as a dietary habit also contributes to the development
of dental caries.[6 ] Depending on the severity of such symptoms, treating children with ADHD in the traditional
dental setting is often quite challenging.[7 ]
Although medications such as stimulants, noradrenergic uptake inhibitors, and tricyclic
antidepressants are standard in the management of ADHD,[8 ] it is crucial for the clinician to be familiar with the signs and symptoms of the
disorder and employ adjunctive behavioral strategies for case management. Audiovisual
distraction (AVD) is one of the methods used to lessen dental anxiety and phobias
in children during dental procedures.[9 ] Music, video display, and recently three-dimensional eyeglass goggle display were
proved to be useful distraction tools during dental treatment in children.[10 ]
Anxiety among children during dental visits can be measured using Frankl and psychometric
scales which rate behavior during dental procedure.[11 ] In addition, pulse rate (PR) and muscle tension readings are indicative of anxiety
and phobias.[12 ] The present study aimed to evaluate the effectiveness of AVD with/without video
eyewear during dental caries assessment and preventive sealant placement in children
with ADHD. The blood oxygen saturation (SaO2 ) and PR will be used as indicators of children’s anxiety during different dental
sessions, with the null hypothesis that AV distractor does not affect the level of
dental anxiety of children with ADHD.
METHODOLOGY
For the present clinical trial, a local facility for ADHD patients’ rehabilitation
was contacted. The study details with consent form and questionnaires were sent to
parents of 31 (n = 21 boys; n = 10 girls) enrolled children aged between 6.5 and 8.1 years. Except for two included
child participants (n = 2; 6.5%), who had a history of dental extractions under general anesthesia, the
rest of all the participants had no previous−3, according to the International Caries
Detection and Assessment System (ICDAS) caries classification, were selected for preventive
sealant placement. However, children with more than two permanent molars with caries
severity of ICDAS codes 4−6 were excluded from the study.
Of the 31 participants, 17 children (54.8%) were grouped as Group A, for they were
not on any medication for ADHD, and another 14 children (45.2%) were arranged in a
separate group (Group B), who were on methylphenidate, a psychostimulant medication
(CONCERTA®, Janssen Pharmaceuticals Inc., Belgium or Ritalin, Novartis Pharmaceuticals
Co., NJ, USA). Research approval was obtained from the Research Ethics Committee,
University of Sharjah, United Arab Emirates. Children accompanied by their parents/caregivers
visited the dental facility at Special-Needs-Teaching Clinic, University Dental Hospital,
Sharjah.
The study comprised four sessions as follows: Session I - behavioral assessment; Session
II -dental screening and charting; Session III - dental prophylaxis; and Session IV
- sealants’ placement [Figure 1 ]. From behavioral assessment to fissure sealant placement, a pediatric dentist (KSF)
was involved during all sessions. A dental assistant (JA) recorded PR and blood SaO2 during all the four sessions.
Figure 1: Patient flow through Sessions I−IV in the research study
Session I
During Session I, baseline assessment of all the study participants was carried out
by a pediatric dentist. In this course, parents/caregivers handed the filled-out questionnaire
to the resident doctors for records in the Patient Health Information system (AxiUm,
Exan Co., Canada). Health information includes patient’s age, general medical conditions,
any comorbid factor (seizure), current medications (if any), dietary habits, past
dental visits, communication skills, and preferences. Under traditional dental setting,
children’s ability to cooperate was assessed and categorized as extraordinarily impulsive/aggressive/restless
by a pediatric dentist. Treatment was planned accordingly as three appointments/sessions
1 week apart.
Employing TELL-SHOW-DO methods of behavior management, a resident doctor demonstrated
how dental drill and suction feels and works by using dental model and play dough.
Playfully, children were introduced to an air-water syringe. In addition, on iPad,
Apple Inc., CA, graphic animations of dental caries were shown to these children.
This serves as an educational tool to help reduce their anxiety and prepare them for
future scheduled treatment. Children were then given the option to select their choice
of age-appropriate cartoon movie from the collection of “Treehousetv.com” website.
They were introduced to a video eyewear (Vuzix Wrap 310XL; Vuzix Corporation, Rochester,
NY, USA) which was attached to the iPad and they were made to watch two cartoon movies,
each 20-min long. At first, participants watched a cartoon movie projected on the
ceiling without wearing the video eyewear. Following this, they watched another cartoon
movie with video eyewear on.
For systematic desensitization with vibrations from dental drills, they were given
powered toothbrushes (oscillating, rotating type). Parents/caregivers were advised
to use these toothbrushes at least twice every day. At the end of Session I, for positive
reinforcement, children were being rewarded with a stuffed toy for following instructions,
by sitting calmly in the dental chair while watching cartoon movies.
Session II - dental screening and charting
For children on ADHD medication, prior to Session II, medication scheme was discussed
and followed as per the advice of the prescribing doctor. This helps optimize the
effect of this drug at the time of the dental procedure, demonstrating improved behavioral
outcome, mostly noticeable within an hour after taking this medication.
A detailed oral examination was recorded using ICDAS index for caries classification.[13 ] Furthermore, for precise diagnosis, intra oral radiographs were taken, if needed,
for participants in either group. During the dental examination of the upper jaw,
children in both groups watched cartoon movie without wearing video eyewear. Though
during the lower-jaw dental examination, they observed a movie using the video eyewear.
Sessions III and IV
The same AVD protocol was followed during dental prophylaxis and sealant application
procedures during Sessions III and IV. Children in either group watched a movie without
video eyewear on while undergoing treatment for their upper teeth. Conversely, during
treatment for lower teeth, both groups were distracted with video eyewear AV distracter
while watching cartoon movie.
Prophylactic cleaning using Prophy paste (Pumice) and low-speed handpiece was done
in Session III. In Session IV, sealants were placed on permanent molars after a professional
cleaning. During placement of sealant, a mouth prop was used to help keep their mouth
open. Where moisture control seemed impossible due to the active tongue, GC-Fuji Triage
sealants were placed after conditioning the tooth. Under ideal moisture control, resin-based
sealants were placed.
During all the sessions (I through IV), blood SaO2 and PR were monitored and recorded every 5 min using fingertip pulse oximeter (PO
80, Beurer GmbH, Ulm, Germany). The changes in the recorded measurements above the
baseline readings were recorded.
To assess the significance of changes in PR and SaO2 during each visit, an independent sample i-test was used to evaluate significance
of change during each appointment visit. Statistical significance was set at P ≤ 0.05.
RESULTS
In the present clinical study, mean age of participants with ADHD was 7.5 years (range:
6.5-8.1 years). Based on those taking medication for ADHD (n = 14) and without (n = 17), the participants were divided into two groups. According to ICDAS criteria
codes, the severity of pit and fissure demineralization of permanent first molars
was assessed and recorded. Of the 31 participants, first permanent molars (n = 119) were evaluated.
Dental evaluation using ICDAS caries assessment tool demonstrated that only (6%) 7
teeth of children on ADHD medication had caries code 0 (caries free), while (2%) 2
children had code 0 in the nonmedication group. Almost 95% (n = 113) of the first permanent molars showed signs of pit and fissure demineralization
of varying severities classified as ICDAS codes 1-3. ICDAS caries code 1 was the most
prevalent on the first permanent molars (n = 52; 44%) found on occlusal surfaces and buccal pits of lower permanent molars.
This was followed by ICDAS code 2 (n = 29; 24%), predominantly observed on occlusal surfaces and palatal pits and fissures
of permanent upper molars. ICDAS code 3 was detected in 27% (n = 32) of the first permanent molars, as shown in [Figure 2 ]. In addition, 5% (n = 6) of the first permanent molars demonstrated caries severity of ICDAS codes 4−6.
Figure 2: The prevalence percentage of each International Caries Detection and Assessment System
code per tooth (n = 119)
There was no significant difference in SaO2 levels or heart rate during the initial three sessions among children using AV distracter
with/without a video eyewear in both groups [Table 1 ]. During baseline assessment, we recorded a noticeable decrease in mean PR among
children in both groups while they were distracted watching a movie using a video
eyewear. Moreover, we observed a gradual reduction of mean changes in PR from initial
to final sessions among children wearing video eyewear in groups (with/without medication)
[Figures 3 ] and [4 ]. This demonstrated a reduction in anxiety level during successive treatment sessions
among children distracted using AV distracter with video eyewear.
Table 1:
Mean changes in blood oxygen saturation and pulse rate among 31 children (Group A:
children not taking medication and Group B: children taking medication)
Treatment session
Mean (SD)
P
AV distracter without video eyewear
AV distracter with video eyewear
SaO2
PR
SaO2
PR
Obtained using t -test; *P <0.05. NS: Not significant, SD: Standard deviation, PR: Pulse rate, AV: Audiovisual,
SaO2 : Oxygen saturation
I (Behavioral assessment)
Group A
5.3 (0.05)
7.5 (1.32)
4.2 (2.13)
4.6 (0.11)
0.07 (NS)
Group B
3.6 (0.32)
6.3 (0.16)
3.0 (1.35)
4.5 (0.26)
0.09 (NS)
II (Dental screening)
Group A
5.2 (0.72)
7.1 (0.06)
4.4 (0.19)
5.0 (1.05)
0.10 (NS)
Group B
4.3 (0.66)
5.9 (0.02)
3.2 (0.01)
4.1 (0.14)
0.08 (NS)
III (Dental prophylaxis)
Group A
4.7 (0.13)
6.7 (0.94)
3.9 (0.02)
4.9 (1.03)
0.11 (NS)
Group B
2.3 (0.13)
4.8 (0.26)
2.8 (0.11)
2.6 (0.15)
0.07 (NS)
IV (Sealant placement)
Group A
3.6 (1.13)
5.8 (0.04)
3.4 (0.14)
2.6 (0.06)
0.05*
Group B
3.6 (0.31)
5.1 (0.12)
3.1 (1.01)
2.2 (0.10)
0.03*
Figure 3: Mean pulse rate during Sessions I-IV with audiovisual distraction without video eyewear
Figure 4: Mean pulse rate during Sessions I-IV with audiovisual distraction using video eyewear
During treatment Session IV, statistically significant differences in mean PR (P ≤ 0.03 and P ≤ 0.05, respectively) were observed among children in both groups who received fissure
sealants on their first permanent molars with caries codes 0, 1, and 2. In our study,
glass ionomer sealants (Fuji VII) were the most commonly used sealant, placed on lower
permanent molars with caries codes 0, 1, and 2. This was followed by resin-based fissure
sealant applied to permanent upper molars. Among Group B children, six of the lower
permanent molars with caries code 3 received preventive resin restoration (PRR-type
B). Conversely, for children in the nonmedication group, PRR-type B was only possible
on one of the four teeth with caries code 3, due to difficulty in moisture control.
These teeth were managed using temporary glass ionomer cement restoration.
DISCUSSION
ADHD is a neurobehavioral condition that often becomes apparent in early childhood.[14 ] The condition interferes with an individual’s ability to attend to tasks and affects
their behavior. Behavioral expressions of the disorder frequently impair the patient’s
ability to perform oral care adequately and make dental appointments stressful and
tiring.[15 ]
The current study targeted a child population that is agreed by most studies to be
a risk group for dental caries and its sequel. In our study, we demonstrated a protocol
which can facilitate caries management at the prepathogenic level (true prevention)
for a highly susceptible group of children aiming to save time and effort which may
be wasted during extensive caries management for exposed and poorly decayed teeth
if the risk in this group of children was overlooked. Corroborating Rosenberg et al’s. (2014) results,[16 ] our study also demonstrated higher caries scores expressed in ICDAS caries codes,
where almost 95% of the first permanent molars showed signs of pit and fissure demineralization
of varying severities.
Almost half the children in our study (n = 14; 45.2%) were on long-acting stimulant (CONCERTA®/Ritalin) medication. Information
related to dosing schedule was obtained from the child’s physician. An early morning
dental appointment was set for all participants. Especially for children on ADHD medication,
morning appointments are ideal, as therapeutic drug concentration in plasma are optimal,
resulting, these children are more attentive during morning hours.
The physiological measures employed in this study were PR and blood-SaO2 . Several studies reported that stress and anxiety cause changes in heart rate and
alter respiration, leading to changes in SaO2 of the blood.[17 ],[18 ] A study by Poiset et al. also reported that measuring SaO2 in the blood is a reliable method for monitoring dental anxiety.[19 ] In the current study, to measure anxiety level during procedure, a small fingertip
device was used to avoid apprehension among these children.
Employing “tell-show-do, modeling, and AVD” approaches during the initial treatment
session assists overcome communication barrier, as observed in this study. Children
with ADHD perform best when they know what to expect.[15 ] Using animated cartoons displayed on tablets, we informed the child about what we
want to accomplish during the appointment. To introduce and desensitize children’s
visual, auditory, and tactile sensations, we demonstrated using tooth model on how
hand-piece, air-water syringe and suction sounds and works. Due to the short attention
span of these children, we demonstrated the procedure in a simple, quick, and fun
way. In addition, the treatment was split into short and positive sessions. These
behavioral modification approaches encourage cooperative behavior among these children,
as evident from the fact that they watch cartoon movie projected on the ceiling above
the chair without any apprehension.
Considering that behaviors which are rewarded lead to improvement toward positive
behavior, a powered toothbrush was given at the end of the first session. This also
helped in systematic desensitization to vibrating stimuli of the dental drills. In
addition, this is useful for obtaining compliance from an ADHD child.
Children with ADHD often become frustrated because inattentive children are easily
distracted.[1 ] These distracting stimuli may result in unusual responses which might cause interruption
during treatment.
To direct their attention away from these distracting stimuli, thoughts, and feel,
we use AVD with video eyewear, similar to our finding from the previous study which
demonstrated that the use of video eyewear might be a better distraction than watching
video projected on the screen.[20 ] In this study, AVD also served as a useful distraction tool showing statistically
significant results with changes in heart rate during dental examination with and
without visual eyewear. As breaks is a critical component in working with ADHD children,
after we finish procedure on upper teeth, children in both groups were given the choice
to select a cartoon movie they prefer before we start the procedure on lower jaw teeth.
Performance bias was avoided in the current trial by involving a dental assistant
(JA), from whom children’s treatment group information was concealed and was assigned
the task of recording levels of SaO2 and PR of all participants during each session. Moreover, to avoid detection and
reporting bias in the study, a dentist (HE) who was not involved at any stage of treatment
sessions did data analysis and reported write-up.
A limitation in the current study might be the use of different types of sealants
where difficulty in moisture control for lower teeth favored the use of glass ionomer
sealant on those teeth. Another comparative study on the long-term protective effect
of different materials for this highly susceptible group of children is recommended.
CONCLUSION
Children with ADHD may show higher caries risk than healthy children. For better behavioral
management, our study recommends splitting the dental visits into multiple short visits
that could lead to better treatment results. In most cases, video eyewear distraction
showed better behavioral management outcome compared to distraction by screen projection.
Financial support and sponsorship
Nil.
