743331

research-article2017
JADXXX10.1177/1087054717743331Journal of Attention DisordersYiu et al.

Article
Journal of Attention Disorders

Oral Health of Children With Attention

1­–16
© The Author(s) 2017
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DOI: 10.1177/1087054717743331
https://doi.org/10.1177/1087054717743331

Review and Meta-Analysis journals.sagepub.com/home/jad

Yvonne C. Y. Chau1, Si-Min Peng1, Colman P. J. McGrath1,

and Cynthia K. Y. Yiu1

Abstract
Objective: This systematic review investigated the oral health of children with ADHD. Method: A structured search
strategy was performed on five electronic databases: SCOPUS, Web of Science, COCHRANE, PubMed, and PsychInfo.
Studies were included in the review if they reported clinical oral health outcomes on a population diagnosed with ADHD
under the age of 18 years old. Qualitative and quantitative analysis was performed on pooled prevalence and mean/median
values for caries, trauma, periodontal problems, and tooth wear. Results: Twenty-seven effective articles were reviewed
by two calibrated assessors. Meta-analysis of the results found higher mean number of decayed surfaces, plaque index,
and trauma prevalence among children with ADHD. Conclusion: Children with ADHD show increased risk for caries
and traumatic dental injuries, and may have poorer oral hygiene compared with children without ADHD. More awareness
among clinicians would promote better caries- and trauma-preventive advice and management. (J. of Att. Dis. XXXX; XX(X)
XX-XX)

Keywords
ADD/ADHD, ADHD, attention deficit hyperactivity disorder, children, oral health

Introduction Kieling, & Rohde, 2014). Symptoms appear to decrease

ADHD (American Psychiatric Association [APA], 2013) or
hyperkinetic disorder (International Statistical Classification
of Diseases and Related Health Problems [ICD-10]; World
Health Organization, 1992) is a neurobehavioral disorder
commonly diagnosed in school-aged children. Symptoms
of inattention, hyperactivity, and impulsivity are associated
with significant functional impairment and frequently occur
with other emotional, behavioral, and learning problems,
including oppositional defiant disorder, conduct disorder,
depression, anxiety, and learning disabilities (APA, 2013;
Larson, Russ, Kahn, & Halfon, 2011).
The literature most commonly refers to the Diagnostic
and Statistical Manual (DSM) criteria for the definition of
ADHD. The development and use of multiple screening
questionnaires and behavioral rating instruments of ADHD
symptoms have also proved popular in many epidemiologi-
cal studies (Brown et al., 2001).
Prevalence rates have varied widely, possibly due to
modifications in diagnostic criteria over time. A review of
worldwide data estimated a pooled prevalence of 7.1%
among children less than 18 years of age (Thomas, Sanders,
Doust, Beller, & Glasziou, 2015), which has not increased
significantly in recent times (Polanczyk, Willcutt, Salum,
with age with a prevalence of 2.5% to 4% among the adult
population (Simon, Czobor, Balint, Meszaros, & Bitter,
2009; Wilens, Faraone, & Biederman, 2004). Males are
diagnosed 3 to 6 times more often than females (Szatmari,
Offord, & Boyle, 1989), although it is believed that ADHD
may be often underdiagnosed in females due to different
clinical manifestations of symptoms (Murray, Naysmith,
Liu, & Drummond, 2012).
Children with ADHD may present with additional medi-
cal issues, such as sleep disorders, encopresis, and enuresis,
or it may be secondary to medical conditions, including
traumatic brain injury, fetal alcohol exposure, lead intoxica-
tion, premature birth, epilepsy, and tic disorders (Charles,
2010). The symptoms of ADHD are generally treated
through behavioral therapy, with or without pharmacologi-
cal intervention. Medications prescribed are commonly
divided into stimulant or nonstimulant drugs. The stimulant
1
The University of Hong Kong, Hong Kong SAR, China
Corresponding Author:
Cynthia K. Y. Yiu, Faculty of Dentistry, Paediatric Dentistry and
Orthodontics, Prince Philip Dental Hospital, The University of Hong
Kong, 34 Hospital Road, Sai Ying Pun, Hong Kong SAR, China.
Email: ckyyiu@hkucc.hku.hk
2 Journal of Attention Disorders 00(0)
medications (such as methylphenidate and amphetamines)
have been implicated in adverse oral effects, such as xero-
stomia and gingival enlargement (Hasan & Ciancio, 2004),
although evidence is scant.
The current evidence is controversial regarding the
severity and prevalence of dental caries, dental trauma,
periodontal disease, and tooth wear among patients with
ADHD. Thus, the potential for increased risk of dental dis-
ease in this population remains undetermined. Clinical oral
health outcomes assessed previously include effects of
medications on salivary function (Grooms, Keels, Roberts,
& McIver, 2005; Hidas et al., 2013; Hidas et al., 2011) and
appetite (Grooms et al., 2005), impaired executive func-
tions and motor coordination affecting oral health behavior
(Broadbent, Ayers, & Thomson, 2004; Grooms et al., 2005;
Hidas et al., 2011; Murray et al., 2012), and behavior man-
agement problems (Atmetlla, Burgos, Carrillo, & Chaskel,
2006; Blomqvist, Holmberg, Fernell, Ek, & Dahllof, 2006),
as well as problems with interpersonal interactions that may
affect trauma occurrence (Murray et al., 2012; Odoi,
Croucher, Wong, & Marcenes, 2002). This study aims to
review the oral health status of patients with ADHD to help
improve management of affected individuals in the dental
setting as well as in the wider public health framework.
Materials and Method
Search Strategy
The search strategy followed Preferred Reporting items for
Systematic Reviews and Meta-Analysis (PRISMA) guide-
lines to identify potentially effective studies from five elec-
tronic databases: Pubmed (including Medline), Cochrane,
Web of Science, SCOPUS, and PsycINFO from all dates
inclusive until November 2016 (Figure 1; Moher, Liberati,
Tetzlaff, & Altman, 2010). Medical subject headings
(MeSH) terms and key words were developed based on pre-
vious systematic reviews of “oral health” (Dai et al., 2015)
and “ADHD” (Polanczyk, de Lima, Horta, Biederman, &
Rohde, 2007; Table 1). Studies were limited to those pub-
lished in the English language.
Duplicates were removed and the remaining “Titles and
abstracts” were reviewed. The first batch of 50 abstracts was
reviewed by two independent assessors (Y.C. and S.M.P.) to
develop criteria for exclusion. These criteria were then
applied to the next batch of 100 abstracts, and congruence
between assessors was determined. All titles and abstracts
were screened to identify “potentially effective studies.”
Full text copies of “potentially effective studies” were
obtained and reviewed using the exclusion criteria framework
developed by the two previous assessors (Y.C. and S.M.P.) to
determine eligibility of “effective studies.” Agreement
between assessors was determined using Kappa statistics.
Disagreement was resolved by a third assessor (C.M.).
An analysis of “effective studies” according to (a) dental
caries, (b) periodontal health status, (c) dental trauma, (d)
tooth wear, and (e) other factors was performed. Details of
study year, site, sample size, clinical assessment criteria,
and outcomes (based on prevalence and mean/median val-
ues) for those with and without ADHD were collected, and
level of statistical significance recorded. Meta-analysis of
the results was performed through the software,
Comprehensive Meta-Analysis (CMA) version 2.0 (Biostat,
Inc. USA).
Results
The search strategy identified 12,254 references from five
databases: 6,146 from Pubmed, 5,057 from SCOPUS
(included EMBASE from 1996), 790 from Web of
Science, 253 from PsychINFO, and eight from the
Cochrane Library. One additional study was found from
manual searching of reference lists. The initial screening
process (Figure 1) yielded 33 potentially effective refer-
ences for full-text analysis (Kappa: 0.773). Only observa-
tional studies (case-control and cross-sectional studies)
that examined oral health status among children (less than
18 years of age) with ADHD were included in the review.
Thus, 26 effective papers (Kappa = 0.835) were included
for qualitative analysis of the pooled clinical outcomes
(based on prevalence and mean/median values) for caries
(n = 12), trauma (n = 16), periodontal health (n = 8), and
tooth wear (n = 2).
Caries Prevalence
Six case-control studies (Table 2) yielded caries preva-
lence data (percentage with caries indices > 0 or mean
unmet treatment needs scores). Only one study reported
data on the primary dentition, and found higher total
caries prevalence among children with ADHD (66%)
compared with healthy children (43%; p = .05; Grooms
et al., 2005). However, the difference was not statisti-
cally significant when caries involving dentine was
analyzed.
Five studies reported on caries prevalence in the per-
manent dentition with three studies reporting significantly
higher caries prevalence in children with ADHD or higher
than average hyperactivity scores (Blomqvist, Ahadi,
Fernell, Ek, & Dahllof, 2011; Broadbent et al., 2004;
Kohlboeck et al., 2013). In one study, significance was
only found when incipient enamel caries was included
(Kohlboeck et al., 2013). The meta-analysis (fixed effect
model: heterogeneity Q = 3.218; df = 3, p > .05; Figure 2)
showed that children with ADHD have more than one and
a half times odds for having caries compared with chil-
dren without ADHD (odds ratio = 1.621; 95% CI = 1.20,
2.179).
Yiu et al.
Figure 1. Search strategy.
Note. PRISMA Flow diagram for reference search on ADHD and oral health.
Caries Extent
One study on primary teeth revealed a significantly higher
mean caries in children with ADHD (Chandra,
Anandakrishna, & Ray, 2009), while the other observed that
significance was found only for incipient enamel caries
(Grooms et al., 2005). The meta-analysis of these two stud-
ies did not show any significant effects (standardized mean
difference = 0.748, 95% CI = −0.725, 2.221; Figure 3). Two
other studies examined the combined caries experience of
both primary and permanent teeth (Decayed, Missing,
Filled Teeth [DMFT]/ decayed, extracted, filled primary
teeth [deft] indices) but found conflicting results. One
reported significantly lower decay levels in children with
3
ADHD (Atmetlla et al., 2006), while the other found no sig-
nificant differences (Hidas et al., 2011).
Despite only one study reporting significantly higher
caries experience in permanent teeth (mean DMFS/DMFT)
among children with ADHD (Blomqvist et al., 2006), four
studies found significantly more decayed surfaces or teeth
(DS/DT; Blomqvist et al., 2011; Blomqvist et al., 2006;
Grooms et al., 2005; Kohlboeck et al., 2013). Both the
meta-analysis of difference in mean DMFT (Figure 4) and
mean DMFS reported nonsignificant effects (Figure 5).
However, a significantly higher mean DS (standardized
mean difference = 0.314, 95% CI = 0.179, 0.449) was
found among children with ADHD in the meta-analysis
4 Journal of Attention Disorders 00(0)

Table 1. MESH Terms and Keywords Used in Search Strategy.

MESH terms Keywords

Oral health “Tooth diseases” “tooth diseases”
“Mouth diseases” “mouth diseases”
“Oral hygiene” “oral hygiene”
“Oral health” “oral health”
“Tooth injuries” “dental deposit”
“dental calculus”
“plaque accumulation” “periodont*”
“gingiv*”
“dental caries”
“tooth decay”
“tooth demineralization”
“tooth decalcification”
“tooth loss”
“tooth extraction”
“probing depth”
“bleeding on probing”
“gingival haemorrhage”
“gingival hemorrhage”
“plaque score”
“DMF index”
“oral clean*”
“tooth injuries”
“dental injuries”
“dental trauma”
ADHD “Attention deficit with “attention deficit with hyperactivity”
hyperactivity disorder” “mental disorders”
“Mental disorders” “attention deficit and disruptive disorders”
“Attention deficit and “psychiatric disorders”
disruptive disorders” “attention-deficit”
“attention deficit/hyperactivity disorder”
“hyperactiv*”
“overactiv*”
“inattent*”
“hyperkinetic disorder”
“minimal brain dysfunction”

Note. MESH = medical subject headings.

*All terms that begun with root word were included in search.

(fixed effect model: heterogeneity Q = 3.932, df = −4, p >
.05), which included results for incipient carious surfaces
(Figure 6).
There were two studies that also reported significant
associations in higher caries levels among children with
ADHD and externalizing behavior problems (Broadbent
et al., 2004; Williamson, Oueis, Casamassimo, &
Thikkurissy, 2008). Conversely, children with caries also
showed a significantly higher proportion of externalizing
problems (which included hyperactivity symptoms) and
attention deficit/hyperactivity issues (Williamson et al.,
2008).
Dental Trauma
The prevalence of traumatic dental injuries ranged from
2.30% to 42% in children with ADHD (Table 3). A
meta-analysis of five studies, including two separate
sample groups from one study (random effect model:
heterogeneity Q = 18.482, df = 5, p = .002) showed that
children with ADHD had 1.5 times higher odds of dental
trauma compared with children without ADHD (95% CI
= 1.169, 2.094; Figure 7).
Two cross-sectional studies indicated a high dental
trauma prevalence (31.6%-42%) in a population of ADHD
children but made no comparisons to controls (Avsar,
Akbas, & Ataibis, 2009; Sabuncuoglu, Taser, & Berkem,
2005). A significantly higher hospital admission was
reported for children with ADHD, although it was not
clear whether the trauma experience included dental inju-
ries (Atmetlla et al., 2006). Furthermore, some studies
have shown a higher prevalence of diagnosed ADHD or
symptoms of hyperactivity/inattentiveness among chil-
dren who had experienced a traumatic dental injury (Bani,
 Table 2. Caries Prevalence and Severity.

Caries prevalence Other values:

Paper and country ADHD criteria Case/control (age) Matching (%) Caries M (SD) M (SD)
Atmetlla, Burgos, Carrillo, and Referred from Psychiatric 36 ADHD cases (5-13 years) No N/A DMFT/deft: 6.8*
Chaskel (2006) Department, then •• no medication on day of exam
(Columbia) SNAP-IV and ADHDT 47 medically healthy controls (5-13 DMFT/deft: 10.0
years)
Bimstein, Wilson, Guelmann, and ADHD medications 25 ADHD cases (90.4 ± 39.6 months) No Unmet treatment DS: 8.1 (12.1)
Primosch (2008) •• all medicated needs† FS: 1.3 (3.0)
(The United States) 76.9 (36.9)
127 medically healthy controls (88.2 81.6 (30.8) DS: 6.5 (7.1)
± 43.6 months) FS: 1.6 (3.8)
Blomqvist, Ahadi, Fernell, Ek, and DSM-IV 32 ADHD cases (17 years) Yes: age DMFS > 0: 94%* DS: 2.0 (2.2)**
Dahllof (2011) DMFS: 6.1 (4.3)
(Sweden) DMFT: 4.6 (2.8)
55 screen-negative controls (17 DMFS > 0: 71% DS: 0.9 (1.4)
years) DMFS: 4.4 (4.9)
DMFT: 3.6 (3.6)
Blomqvist, Holmberg, Fernell, Ek, DSM-IV 21 ADHD cases (13 years) Yes: age DMFS > 0: 62% DS: 1.0 (2.2)
and Dahllof (2007) •• 2 methylphenidate; 1 amphetamine DMFS: 2.8 (4.0)
(Sweden) 79 screen-negative controls (13 DMFS > 0: 52% DS: 0.7 (1.5)
years) DMFS: 2.2 (3.2)
Blomqvist, Holmberg, Fernell, Ek, DSM-IV 25 ADHD cases (11 years) Yes: age N/A DMFS: 2.0 (3.0)*
and Dahllof (2006) DS: 1.7 (3.6)*
(Sweden) 58 screen-negative controls (11 DS: 0.5 (0.9)
years) DMFS: 1.0 (1.5)
Broadbent, Ayers, and Thomson ADHD positive medical 128 high caries load cases (11-13 Yes: gender, DMFT > 5: OR = N/A
(2004) history years) school 10.2* [95% CI
(New Zealand) •• DMFT > 5 decile, 1.3, 91.8]
•• 11 ADHD cases (8 medicated) ethnicity, age
•• 128 low caries load controls (11-
13 years)
•• DMFT ≤ 4
•• 3 ADHD cases (1 medicated)
Chandra, Anandakrishna, and Ray Connor’s questionnaire 40 ADHD cases (6-14 years) Yes: age, N/A defs: 8.9 (4.9)**
(2009) medicated and non-medicated gender, SES DMFS: 1.1 (1.2)
(India) 40 medically healthy controls (6-14 defs: 2.9 (2.8)
years) DMFS: 0.7 (1.0)

(continued)

5
6
Table 2. (continued)
Caries prevalence Other values:
Paper and country ADHD criteria Case/control (age) Matching (%) Caries M (SD) M (SD)
Grooms, Keels, Roberts, and DSM-IV 38 ADHD cases (6-11 years) Yes: age, race, d(1)mfs > 0: 66% dmfs: 5.8 (8.8) d(1)s: 1.0
McIver (2005) •• 30 methylphenidate gender, SES d(3)mfs > 0: 50% DMFS: 0.9 (2.0) (2.3)*
(The United States) •• 7 dextroamphetamine D(1)S: 0.6
•• 12 nonstimulant medication (1.9)*
38 medically healthy controls (6-11 d(1)mfs > 0: 43% dmfs: 5.8 (10.8) d(1)s: 0.3 (1.2)
years) d(3)mfs > 0: 35% DMFS: 0.6 (1.5) D(1)S: 0 (0)
Hidas et al. (2011) DSM-IV 31 ADHD1 cases (5.9-16.7 years) No N/A DMFT/dmft: 2.6 (2.3)
(Israel) •• nonmedicated
30 ADHD2 cases (6.7-17.2 years) DMFT/dmft: 4.3 (3.8)
•• methylphenidate medication
30 medically healthy controls (6.0- DMFT/dmft: 4.1 (3.6)
17.8 years)
Kohlboeck et al. (2013) SDQ 161 cases (9.8-11.8 years) Yes: age DT > 0: 1.9% DMFT: 0.3 (0.7) D(1)S: 2.0
(Germany) •• borderline or abnormal HA/IA D(1)MFS > 0: DMFS: 0.4 (1.0) (2.8)**
values 57.1%* FT: 0.2 (0.7)
•• 16 methylphenidate or FS: 0.3 (0.9)
atomoxetine
965 controls (9.8-11.8 years) DT > 0: 2.3% DMFT: 0.3 (0.8) D(1)S: 1.4
•• normal HA/IA values D(1)MFS > 0: DMFS: 0.4 (1.2) (2.1)
•• no ADHD medication 47.0% FT: 0.3 (0.8)
FS: 0.4 (1.2)
Williamson, Oueis, Casamassimo, CBC 60 cases (30-60 months) No N/A ADHD scores: 54.8
and Thikkurissy (2008) CA: requiring general anaesthesia for (7.1)*
(The United States) dental treatment Externalizing problem
scores: 49.3 (10.7)*
60 controls (30-60 months) ADHD scores: 52.2
medically healthy (4.4)
CF Externalizing problem
scores: 44.7(9.4)

Note. SNAP-IV = Swanson, Nolan, and Pelham Questionnaire; ADHDT = Attention Deficit Hyperactivity Disorder Test; defs = decayed, extracted, filled surfaces for primary dentition; dmft = de-
cayed, missing, filled teeth for primary dentition; DMFT = decayed, missing, filled teeth; DMFS = decayed, missing, filled surfaces; DS = decayed surfaces; D(I)S = decayed incipient surfaces; FT = filled
teeth; FS = filled surfaces; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994); OR = odds ratio; CI = confidence interval; SDQ = Strength
and Difficulties Questionnaire (parent-reported); HA = hyperactivity; IA = inattention; DT =decayed teeth; CBC = Child Behaviour Checklist; CA = caries active; CF = caries free; CTQ = Conner’s
Teacher Questionnaire; ARS = Attention Deficit/Hyperactivity Disorders Rating Scale; CRS-Revised = Connor’s Rating Scale–Revised; CPRS-RS = Conner’s Parent Rating Scale–Revised (Short form);
SES = socio-economic status.
†
M (SD) value.
*p < 05. **p < .01.
Yiu et al. 7

Figure 2. Difference in caries prevalence (fixed effect).

Note. Graph showing meta-analysis results of caries prevalence among children with ADHD: heterogeneity Q = 3.218; df = 3; p = .359. CI = confidence
interval.

Figure 3. Difference in mean DMFT/deft (random effect).

Note. Graph showing meta-analysis results of caries status among children with ADHD in primary dentition: heterogeneity Q = 19.361; df = 1; p < .001.
CI = confidence interval; deft = decayed, extracted, filled teeth for primary dentition; DMFT = decayed, missing, filled teeth.

Figure 4. Difference in mean DMFT (fixed effect).

Note. Graph showing meta-analysis results of caries status with regard to permanent teeth among children with ADHD: heterogeneity Q = 1.506; df =
1; p = .209. CI = confidence interval; DMFT = decyaed, missing, filled teeth.

Bodur, & Kapci, 2015; Herguner, Erdur, Basciftci, & studies reported no such trend (Odoi et al., 2002;
Herguner, 2015; Mota-Veloso et al., 2016), while other Thikkurissy, McTigue, & Coury, 2012).
8 Journal of Attention Disorders 00(0)

Figure 5. Difference in mean DMFS (fixed effect).

Note. Graph showing meta-analysis results of caries status (assessing tooth surfaces) with regard to permanent teeth among children with ADHD:
heterogeneity Q = 6.680; df = 5; p = .246. CI = confidence interval; DMFS = decayed, missing, filled surfaces.

Figure 6. Difference in mean DS (fixed effect).

Note. Graph showing meta-analysis results of carious tooth surfaces among children with ADHD in permanent dentition: heterogeneity Q = 3.932; df =
4; p = .415. DS = decayed surfaces; D(I)S = decayed incipient surfaces; CI = confidence interval.

Oral Hygiene—Plaque Index study reported significantly higher results in 17-year-old

Five case-control studies (Table 4) assessed plaque levels
using the Löe and Silness method (Silness & Loe, 1964) and
the O’Leary index (O’Leary, Drake, & Naylor, 1972). A
meta-analysis (random effect model: heterogeneity Q
=18.311, df = 2, p < .001) was performed for three studies
(Hasan & Ciancio, 2004; Hidas et al., 2011; Kohlboeck et al.,
2013) and found significant effects of higher mean plaque
index scores among children with ADHD (standardized
mean difference = 0.758, 95% CI = 0.033, 1.483; Figure 8).
Periodontal Disease
Despite the tendency of children with ADHD to have higher
levels of gingival inflammation, only one case-control
adolescents with ADHD (Blomqvist et al., 2011; Table 4).
Three of the studies used the Axelsson and Lindhe method
to assess gingival inflammation (Axelsson & Lindhe, 1975),
while the others used the Löe and Silness gingival index
(Silness & Loe, 1964), Turesky’s modified gingival index
(Turesky, Gilmore, & Glickman, 1970), or gingival sulcus
bleeding index (Muhlemann & Son, 1971). The meta-anal-
ysis for difference in mean gingival index scores showed no
significant differences between children with ADHD and
those without ADHD.
No significant difference in calculus was detected
(Bimstein, Wilson, Guelmann, & Primosch, 2008), but one
study revealed significantly higher levels of gingival
enlargement (Hasan & Ciancio, 2004) in children with
ADHD who were medicated.
 Table 3. Dental Trauma Prevalence.

Dental trauma prevalence

Paper and country ADHD criteria Case/control (age) Matching (M ± SD or %) Notes
Altun, Guven, Akgun, and Cases referred 97 ADHD cases (7-15 years) Yes: gender, 17.5% Clinical exam
Acikel (2012) from psychiatric 97 medically healthy controls (7-15 age 16.5% (WHO classification)
(Turkey) department years)
Atmetlla, Burgos, Carrillo, and Referred from 36 ADHD cases (5-13 years) No 62.2% hospital* Parental report
Chaskel (2006) psychiatric •• no medication on day of exam
(Columbia) department, then 47 medically healthy controls (5-13 37.8% hospital
SNAP-IV and years) Lower % trauma
ADHDT Not explicitly dental trauma
Avsar, Akbas, and Ataibis DSM-IV 247 ADHD cases (7-16 years) N/A 31.6% Clinical exam
(2009) •• no previous therapy (WHO classification)
(Turkey) •• no medications
no controls
Bani, Bodur, and Kapci (2015) CRS-Revised 80 dental trauma cases (7-15 years) No HA: OR = 1.7 (males only)a Clinical exam
(Turkey) •• traumatic dental injury in previous 2 HA symptoms: 64.3% (males) (WHO classification)
weeks Waldd χ2 = 5.0, df = 1*
80 control (7-15 years) HA symptoms: 44% (males)
•• no dental injury, but have other
dental problems, for example, caries
•• medically healthy
Bimstein, Wilson, Guelmann, ADHD medications 25 ADHD cases (90.4 ± 39.6 months) No 26%** Retrospective data from
and Primosch (2008) •• all medicated patient’s dental records:
(The United States) 127 medically healthy controls (88.2 ± 6% Parental reports
43.6 months)
Blomqvist, Holmberg, Fernell, DSM-IV 128 ADHD cases (1-10 years) No 28% Retrospective data from
and Dahllof (2004) 131 screen-negative controls (1-10 years) 34% patient’s dental records
(The United States)
Herguner, Erdur, Basciftci, and CPRS-R 55 dental trauma cases (7-16 years) Yes: gender, HA score: 4.1 ± 3.7* Clinical exam
Herguner (2015) age Correlation r = 0.24** with (WHO classification)
(Turkey) past history of dental trauma
and HA
55 control (7-16 years) HA score: 2.7 ± 2.6
•• no dental trauma
Katz-Sagi, Redlich, Brinsky- ADHD medication 24 ADHD cases (5-12 years) No 29.1%* Clinical exam (author’s own
Rapoport, Matot, and Ram (methylphenidate) •• medicated classification)
(2010) 22 medically healthy controls (5-12 4.5% + Parental reports
(Israel) years)
Kohlboeck et al. (2013) SDQ 161 cases (9.8-11.8 years) Yes: age Mean number TDI: 1.9 ± 0.3 Clinical exam
(Germany) •• borderline or abnormal HA/IA values (WHO classification)
•• 16 methylphenidate or atomoxetine
965 controls (9.8-11.8 years) Mean number TDI: 1.9 ± 0.3
•• normal HA/IA values
•• no ADHD medication

9
(continued)
10
Table 3. (continued)

Dental trauma prevalence

Paper and country
Lalloo (2003)
(The United Kingdom)
Mota-Veloso et al. (2016)
(Brazil)
Odoi, Croucher, Wong, and
Marcenes (2002)
(The United Kingdom)
Ramchandani, Marcenes,
Stansfeld, and Bernabe
(2016)
(The United Kingdom)
Sabuncuoglu, Taser, and
Berkem (2005)
(Turkey)
Staberg, Noren, Johnson, DSM-IV
Kopp, and Robertson (2014)
(Sweden)
Thikkurissy, McTigue, and ARS-IV
Coury (2012)
(The United States)
ADHD criteria Case/control (age) Matching (M ± SD or %) Notes
SDQ 1,057 cases (4-15 years) No High HA: 2.3%* (OR = 2.0 [1.1, Parental ± child’s report
•• 417 borderline HA 3.5])
•• 640 high HA values Borderline HA: 1.3%* (OR =
2.6 [1.4-4.9])
4,034 controls (4-15 years) 1.2%
•• normal HA values
SNAP-IV 115 dental trauma cases (7-12 years) Yes: age, HA: OR = 2.3 (1.1-4.9)*b Clinical exam
115 control (7-12 years) gender (O’Brien criteria)
•• no traumatic dental injuries
•• no systemic disorders
SDQ 85 dental trauma cases (7-15 years) Yes: age, HA: OR =1.1 (0.4-2.8)c Clinical exam
•• trauma within 12 months gender
85 control (7-15 years)
•• no traumatic dental injuries
SDQ–self-reported 87 cases (15-16 years) No 17% Clinical exam
•• HA in top decile HA: OR = 0.8 (0.4-1.5)d (WHO classification)
707 control (15-16 years) 15%
•• normal HA values
DSM-IV + CTQ 235 ADHD cases (8-17 years) No 12.8%** (OR = 17.4 [4.1-73.6]) Parental + child’s report
•• 95 with psychiatric comorbidities
240 non-ADHD controls (8-17 years) 0.8%
•• 33 with psychiatric comorbidities
31 ADHD cases (5-19 years) N/A 42% Parental report
•• 26 with psychiatric comorbidities
•• 28 medicated
88 dental trauma cases (6-18 years) No HI/IA symptoms: 21% Clinical exam
•• trauma within 6 months ADHD diagnosis: 18%
73 controls (6-18 years) HI/IA symptoms: 18%
•• no traumatic dental injuries ADHD diagnosis: 10%

Note. WHO = World Health Organization; SNAP-IV = Swanson, Nolan, and Pelham Questionnaire; ADHDT = Attention Deficit Hyperactivity Disorder Test; DSM-IV = Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994); CRS-R = Revised Connor’s Rating Scale–Revised; OR = odds ratio; CPRS-R = Conner’s Parent Rating Scale–Revised; SDQ
= Strength and Difficulties Questionnaire (parent-reported); HA = hyperactivity; IA = inattention; CI = confidence interval; CTQ = Conner’s Teacher Questionnaire; ARS = Attention Deficit/Hyperac-
tivity Disorders Rating Scale.; TDI = traumatic dental injury.
a
Hyperactivity symptoms only found to be risk factor for males, not females.
b
Adjusted for “type of school” and overjet.
c
Fully adjusted by problems behavior, parent’s level of education, size of overjet, and type of lip coverage.
d
Adjusted for gender, age, ethnicity, parental employment, overjet.
*p < .05. **p < .01.
Yiu et al.
Figure 7. Difference in trauma prevalence (random effect).
Note. Graph showing meta-analysis results of trauma prevalence among children with ADHD: heterogeneity Q = 18.482; df = 5; p = .002. CI = confi-
dence interval.
Tooth Wear
Only two case-control studies provided data on clinical mea-
sures of tooth wear, and both reported significantly more
tooth wear facets among children with ADHD (Atmetlla
et al., 2006; Malki, Zawawi, Melis, & Hughes, 2004; Table
5). One study showed that children taking CNS (central ner-
vous system) stimulant medication had significantly greater
signs of tooth wear than both nonmedicated children with
ADHD and healthy controls (Malki et al., 2004).
Discussion
Studies were screened with a reasonable level of agreement
between reviewers. Both case-control and cross-sectional
designs were included due to the small number of studies
involved. The exclusion of non-English publications may have
contributed to publication bias; however, attempts to minimize
the effect were made with the screening of multiple databases.
Due to the small sample sizes and range of ages from 30
months old to 19 years of age, it was challenging to com-
pare data from various combinations of primary, mixed, and
permanent dentition stages. Furthermore, many of the stud-
ies did not include a confirmed medical diagnosis of ADHD.
Instead, some authors described the use of ADHD medica-
tion or screening questionnaires and behavioral rating scales
to identify case patients with hyperactivity or inattention
problems. The inconsistent diagnostic criteria likely
affected the validity of the analysis as some ADHD patients,
especially those receiving medical treatment, may screen
negatively for behavioral problems in larger population
studies. Alternatively, some subjects who screen positively
may not fulfill the criteria for diagnosis of ADHD.
Caries
There has been growing interest in the caries status among
children with ADHD, particularly when symptoms may
11
impact oral hygiene practices, and from potential side
effects of medications on salivary function and appetite
(Grooms et al., 2005; Hidas et al., 2013; Hidas et al., 2011).
In addition, the higher prevalence of behavior management
problems among this population in the dental office may
adversely affect the number of teeth with untreated decay
(Atmetlla et al., 2006; Blomqvist et al., 2006).
The meta-analysis of caries prevalence studies showed
significantly higher odds for caries prevalence among chil-
dren with ADHD. However, results were inclusive of a
broad age group from 6 to 17 years of age and did not delin-
eate effects on different stages of dentition. The higher
prevalence of incipient caries in the primary teeth of chil-
dren with ADHD compared with healthy controls may indi-
cate a reversibility of lesion progression in this age group
(Grooms et al., 2005). The meta-analysis did not show sig-
nificantly higher severity of enamel caries in the primary
dentition, and was limited in interpretation by the inclusion
of only two studies.
In the permanent dentition, the majority of case-control
studies reported significantly higher caries prevalence in
young adolescents with ADHD or symptoms of hyperactiv-
ity (Blomqvist et al., 2011; Broadbent et al., 2004;
Kohlboeck et al., 2013). In these studies, significance was
again confined to incipient enamel caries (Kohlboeck et al.,
2013), or occurred in older age groups (17 years of age;
Blomqvist et al., 2011). The results may indicate that caries
experienced by children with ADHD is predominantly
reversible in their earlier years up to young adolescence,
and can be prevented by early intervention with caries pre-
ventive strategies.
Many studies reported no differences in caries experi-
ence for permanent teeth, which was confirmed by the
results of the meta-analysis; however, some studies included
children in the mixed dentition stages (Chandra et al., 2009;
Grooms et al., 2005; Kohlboeck et al., 2013). One study that
found higher caries mean scores in permanent teeth in fact
12
Table 4. Periodontal Health.

Oral hygiene: Gingival Bleeding Index/ Other periodontal

Plaque index inflammation markers
Paper and country ADHD criteria Case/control (age) Matching (M ± SD or %) (M ± SD or %) (M ± SD or %)
Bimstein, Wilson, Guelmann, ADHD medications 25 ADHD case (90.4 ± 39.6 months) No Prevalence: 83% Prevalence: 73% Prevalence: Calculus
and Primosch (2008) •• all medicated 57%
(USA) 127 medically healthy controls (88.2 ± Prevalence: 86% Prevalence: 65% Prevalence: Calculus:
43.6 months) Löe & Silness (PI) Löe & Silness (GI) 30%
Blomqvist, Ahadi, Fernell, Ek, DSM-IV 32 ADHD cases (17 years) Yes: age 35% ± 39%*
and Dahllof (2011) 55 screen-negative controls (17 years) 16% ± 24%
(Sweden) Axelsson & Lindhe
Blomqvist, Holmberg, Fernell, DSM-IV 21 ADHD cases (13 years) Yes: age 7.0% ± 5.4% [95% CI
Ek, and Dahllof (2007) •• 2 methylphenidate; 1 amphetamine 4.5, 9.4]
(Sweden) 79 screen-negative controls (13 years) 8.1% ± 6.3% [95% CI
6.7, 9.5]
Axelsson & Lindhe
Blomqvist, Holmberg, Fernell, DSM-IV 25 ADHD cases (11 years) Yes: age 4.3% ± 4.5%
Ek, and Dahllof (2006) 58 screen-negative controls (11 years) 4.1% ± 4.5%
(Sweden) Axelsson & Lindhe
Chandra, Anandakrishna, and Connor’s questionnaire 40 ADHD cases (6-14 years) Yes: age, Higher*
Ray (2009) medicated and nonmedicated gender, SES (Data not given)
(India) 40 medically healthy controls (6-14 O’Leary (PI)
years)
Hasan and Ciancio (2004) ADHD medication 20 ADHD cases (6-14 years) No 1.1 ± 0.1 0.9 ± 0.1 Gingival enlargement:
(USA) (dextroamphetamine) •• medicated 1.2 ± 0.2**
20 medically healthy controls (6-14 0.9 ± 0.1 0.6 ± 0.1 Gingival enlargement:
years) Löe & Silness (PI) Turesky (Modified GI) 0.6 ± 0.1
•• no medications
Hidas et al. (2011) DSM-IV 31 ADHD1 cases (5.9-16.7 years) No 1.9 ± 0.7**
(Israel) •• nonmedicated (ADHD 1 + 2)
30 ADHD2 cases (6.7-17.2 years)
1. methylphenidate medication
30 medically healthy controls (6.0- 1.4 ± 0.6
17.8 years) Löe & Silness (PI)
Kohlboeck et al. (2013) SDQ 161 cases (9.8-11.8 years) Yes: age 2.4 ± 1.8* 2.04 ± 2.10
(Germany) borderline or abnormal HA/IA values (n.s. in fully
16 methylphenidate or atomoxetine adjusted models)
965 controls (9.8-11.8 years) 2.0 ± 1.8 1.80 ± 2.02
normal HA/IA values Löe & Silness (PI) Muhlemann & Son
no ADHD medication (GSB^)

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994); CI = confidence interval; HA = hyperactivity; IA = inattention; SES = socio-eco-
nomic status; PI = plaque index; GSB = gingival sulcus bleeding; GI = gingival index.
*p < .05. **p < .01.
Yiu et al. 13

Figure 8. Difference in mean plaque index (random effect).

Note. Graph showing meta-analysis results of plaque levels among children with ADHD: heterogeneity Q = 18.311; df = 2; p < .001. CI = confidence
interval; PI = plaque index.

Table 5. Tooth Wear.

Tooth wear/ attrition (M
Paper and country ADHD criteria Case/control (age) Matching ± SD or %) Other information

Atmetlla, Burgos, Referred from 36 ADHD cases (5-13 No 1.3* facets (0-9 affected Physiological attrition (n.s.)
Carrillo, and Psychiatric years) teeth)
Chaskel (2006) Department, then •• no medication on day
(Columbia) SNAP-IV and ADHDT of exam
47 medically healthy 0.5 facets (0-5 affected
controls (5-13 years) teeth)
Unreported index
Malki, Zawawi, Melis, Positive medical history 30 ADHD cases (5-15 Yes: age, gender 6.1 ± 1.2 teeth** ADHD + med: 7.2 ± 1.4
and Hughes (2004) years) Med: 7.2 ± 1.4 teeth** teeth**
(The United States) •• 24 medicated No med: 1.8 ± 0.8 teeth ADHD (no med): 1.8 ± 0.8
30 medically healthy 1.5 ± 0.5 teeth teeth
controls (5-15 years) Unreported index CNS stimulants: 8.9 ± 1.5
teeth*
Nonstimulant: 3.0 ± 0.9
teeth

Note. SNAP-IV = Swanson, Nolan, and Pelham Questionnaire; ADHDT = Attention Deficit Hyperactivity Disorder Test; CNS = central nervous system.
*p < .05. **p < .01.

assessed children aged 11 years old (Blomqvist et al., 2006).
When the caries scores for both permanent and primary
teeth were combined, the lower and nonsignificant caries
scores among ADHD subjects (Atmetlla et al., 2006; Hidas
et al., 2011) may be explained by the possible higher acces-
sibility of children with ADHD to health care services .
Among children with ADHD, the meta-analysis showed
significantly higher levels of decayed surfaces, and it is
important to note studies were predominantly conducted on
children in the mixed dentition stage. The results are indica-
tive of a higher caries risk for permanent teeth among
ADHD subjects, even during the earlier years in mixed den-
tition stage.
Other studies compared the proportion of ADHD sub-
jects in high or low caries risk groups (Broadbent et al.,
2004; Williamson et al., 2008). Due to the different group-
ing criteria of subjects and broad age range, comparisons of
results should be interpreted with caution. As the majority
of studies included children in the mixed dentition stage, it
is difficult to infer any significant differences (or lack of) in
caries experience for children with ADHD during the pri-
mary dentition or permanent dentition stages.
Trauma Prevalence
Traumatic injuries has long been associated with children
diagnosed with ADHD and is often attributed to problems
with peer relationships (Odoi et al., 2002), risk of physical
abuse (Waldman, Swerdloff, & Perlman, 2000), and motor
coordination issues (Fliers et al., 2008). The association of
ADHD with dental traumatic injuries, however, is less
established, and is not helped by the variety in assessment
technique, including clinical indices, parental or patient
reports, and retrospective data from patient records.
14
Results were difficult to compare because of different
case selection criteria (e.g., medication use, behavior ques-
tionnaire, psychiatric referrals), as well as variations in the
reporting of trauma outcomes, which included odds ratio,
prevalence proportions, and mean number of teeth affected.
Also, many studies described only hyperactivity symptoms
or included psychiatric comorbidities. One study (Bani
et al., 2015) found significantly higher odds for dental
trauma with males with ADHD only. The meta-analysis
confirmed that children with ADHD had 1.5 higher odds in
experiencing dental trauma than non-ADHD controls. Thus,
clinicians should be aware of the increased risk of traumatic
dental injuries among children with ADHD and provide
trauma-preventive advice or management accordingly.
Periodontal Health
The meta-analysis showed significantly higher plaque
scores among children with ADHD. Interestingly, children
prescribed ADHD medications do not seem to have similar
levels of poor oral hygiene (Bimstein et al., 2008; Hasan &
Ciancio, 2004). Subject inclusion criteria again varied in
medication use among ADHD children as well as in ADHD
assessment.
Gingival health was also assessed using a variety of indi-
ces among the six case-control studies included in the
review. Data were reported as prevalence among sample
groups, proportion of sites affected, and mean gingival
bleeding scores. The meta-analysis did not identify any sig-
nificant differences in gingival inflammation between chil-
dren with or without ADHD, despite obvious differences in
plaque levels.
Studies that included additional markers of periodontal
disease also found no significant differences in presence of
calculus (Bimstein et al., 2008). One study observed signifi-
cant levels of gingival enlargement in ADHD children who
were medicated, which surprisingly could not be attributed
to poor oral hygiene practices (Hasan & Ciancio, 2004).
More research is required to further clarify these findings.
The generalized limited data on periodontal outcomes may
be explained by the young ages of the study populations.
Tooth Wear
Although many studies reported on the prevalence of brux-
ism, only two case-control studies provided data on clinical
measures of tooth wear. Since previous studies have refuted
the association between reported bruxism and tooth wear
(Seligman, Pullinger, & Solberg, 1988), only studies with
clinical data were included in the review. Both reported sig-
nificantly more tooth wear facets among children with
ADHD (Atmetlla et al., 2006; Malki et al., 2004) although
a meta-analysis could not be performed due to differences
in data reporting systems. The use of CNS stimulant
Journal of Attention Disorders 00(0)
medication may be associated with significantly greater
levels of tooth wear (Malki et al., 2004), but further research
is required to confirm.
Limitations
Unfortunately, meta-analysis of the results could only be
performed on a limited number of studies due to the nature
of the reported data, including methodological differences.
The broad age range among sample groups also hampered
interpretation of the data. The need for standardized indices
is recommended for better comparison of results.
It is recommended that further research of standardized
methodology be conducted to clarify the oral health status
of patients with ADHD and the effect of the different medi-
cations. Not only will this aid dental practitioners in better
managing the oral health of these individuals, but it would
also be beneficial from a public health perspective. This is
particularly relevant among adolescents with ADHD, in the
permanent dentition stage, which are currently under-repre-
sented in the literature. The clarification of dental disease
burden in this age group can have implications for future
restorative needs during adulthood.
Conclusion
Meta-analysis of pooled clinical data indicates significantly
higher number of decayed surfaces (including incipient
enamel caries) in permanent teeth, higher plaque scores,
and higher dental trauma risk among children with ADHD.
The review highlights the importance of incorporating den-
tal preventive advice when treating children with ADHD,
particularly in terms of caries and trauma prevention.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Yvonne C. Y. Chau completed her postgraduate research on oral
health outcomes among children with ADHD. She now works as a
staff specialist at the Department of Pediatric Dentistry, Sydney
Dental Hospital, Australia.
Si-Min Peng is a part-time clinical lecturer in pediatric dentistry,
Faculty of Dentistry, the University of Hong Kong.
Colman P. J. McGrath is a clinical professor in dental public
health, Faculty of Dentistry, the University of Hong Kong.
Cynthia K. Y. Yiu is a clinical professor in pediatric dentistry,
Faculty of Dentistry, the University of Hong Kong.