CASE REPORT

Orthodontics Treatment Strategy and Management in a

Child with Attention Deficit Hyperactivity Disorder
Ricky Kurniawan, Sindy Cornelia Nelwan, Udijanto Tedjosasongko and Tania Saskianti

Department of Pediatric Dentistry, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia

ABSTRACT
This is a case of an 8-year-old male patient diagnosed with class 1 angle malocclusion, 9 mm overjet and 4.5 mm overbite,
with thumb-sucking habit. The patient also has attention deficit hyperactivity disorder (ADHD). The goal of this study is to
identify and determine appropriate orthodontics treatment management for patients with ADHD. Management behavior using
behavioral shaping and tell-show-do technique during orthodontic treatment in patients with special needs contributes to how
well the patient will cooperate with the dentists during treatment.

Key Words: ADHD, Orthodontic development, management ADHD

InTRODuCTIOn

Attention deficit hyperactivity disorder (ADHD), one

of the most commonly diagnosed childhood behavioral
disorders, is characterized by inappropriate inattention,
impulsivity, and hyperactivity. These symptoms may persist
into adulthood and result in lifelong impairment. 1 These
individuals are in communities served by our institution
and are dependent on services from dental and medical
providers, including orthodontic treatment.2

CASe RepORT

This is a case report of an 8-year-old, male patient

diagnosed with class 1 angle malocclusion, 9 mm overjet
and 4.5 mm overbite, impacted tooth 45, with thumb-
sucking habit. Figures 1-3 show the profile of the patient
on his first visit. The patient is also diagnosed with attention
deficit hyperactivity disorder (ADHD) two years ago by a
psychologist. The patient receives counseling and therapy
once a week.
In order to treat the malocclusion, the patient underwent
a surgical procedure to fix tooth 45 using removable
orthodontics using palatal cribs. After 18 months, the
thumb sucking habit is corrected and proceeded to use fixed
orthodontic treatment for permanent management (Figure 4).
The patient comes to the pediatric dentistry clinic and
Paper presented at the Joint Scientific Meeting in Special Care receives treatment for 1.5–2 hours. For the first hour of the
Dentistry, July 5, 2019, Amerta Room, 4th Floor, main campus of
Universitas Airlangga, Surabaya, Indonesia. treatment, the patient is still cooperative, but after 30-60
minutes the patient starts to show signs of discomfort like
Corresponding author: Sindy Cornelia Nelwan trolling, messing the dental care or diagnostic kit, trying
Department of Pediatric Dentistry to punch and push things, including the dental chair, and
Faculty of Dental Medicine Universitas
Airlangga operator. We were able to manage the mood in order to
Jl. Mayjen. Prof. Dr. Moestopo No. 47 Surabaya 60132 – Indonesia finish the treatment on the first day, by doing interventions
Email: [email protected] like playing or giving some space, distracting the patient

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Orthodontic Treatment in ADHD Child

Figure 1. Extraoral profile of the patient.

Figure 2. Intraoral profile of the patient.

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Figure 3. Radiographs (A) Panoramic, (B) Cephalometry.

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Figure 4. Intraoral (still in progress).

for a while by carrying him around and showing him

to affect performance in school, social relationships, or
things. Afterwhich he will calm down and sit in the dental
behavior at home, it can be suspected as characteristics of a
chair and be cooperative again. After the first session and
child with ADHD.3
continuous interventions, the ADHD symptoms seem to
Symptoms of ADHD are divided into three groups:
get better evidenced by the patient being more cooperative,
difficult to focus (inattentiveness), being extremely
quiet and the parents expressed more understanding about
active (hyperactivity), and cannot control their behavior
the treatment.
(impulsivity). Some children with ADHD have mainly
inattentive symptoms; some have mainly hyperactive and
DISCuSSIOn impulsive symptoms. Others have a combination of different
symptom types. Those with mostly inattentive symptoms are
The ADHD characteristics are divided into three types;
sometimes said to have attention deficit disorder (ADD).
inattention, hyperactivity, and impulsivity. These symptoms
They tend to be less disruptive and are more likely not to
appear in the child’s early life but because many children
be diagnosed with ADHD.4, 5
without ADHD may also have these symptoms, but at
a low level, or the symptoms may be caused by another
Inattentive Symptoms
disorder, children should receive a thorough examination
Fails to give close attention to details or makes careless
and appropriate diagnosis by a well qualified professional
mistakes in schoolwork, has difficulty keeping attention
for an accurate and correct diagnosis and management plan.
during tasks or play, does not seem to listen when spoken
Symptoms of ADHD will appear over the course of many
to directly, does not follow through on instructions and
months, it is very often to find the symptoms of
fails to finish schoolwork or chores and tasks, has problems
impulsiveness and hyperactivity preceding those of
organizing tasks and activities, avoids or dislikes tasks that
inattention that may not appear for a year or more.
require sustained mental effort (such as schoolwork), often
Symptoms can appear in different characteristics and
loses toys, assignments, pencils, books, or tools needed for
depends on the situation that can pose for the child’s self-
tasks or activities, is easily distracted, and it is often
control. When hyperactivity, distractibility, difficult
forgetful in daily activities.5
concentration, or impulsivity begins

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 Orthodontic Treatment in ADHD Child

Hyperactivity Symptoms
Consistency, setting limits and clear instructions help
Those children fidgets with hands or feet or squirms
in managing the child’s behavior. For patients with ADHD,
in seat, leaves seat when remaining seated is expected, runs
putting together a daily routine with clear expectations that
about or climbs in inappropriate situations, has problems
include such things as bedtime, morning time, mealtime,
playing or working quietly, is often "on the go, " acts as if
simple chores, and TV is very important. Make eye contact
"driven by a motor", talks excessively.5
when giving instructions, and set aside a few minutes to
praise the child. Work with teachers and caregivers to
Impulsivity Symptoms
identify problems early to decrease the impact of the
Blurts out answers before questions have been
condition.5, 6
completed, has difficulty awaiting turn, interrupts or
During orthodontic treatment, we required a
intrudes on others (butts into conversations or games).5
routine checkup to monitor the progress once a month.
When treating patients, similar to any other child,
A partnership between the health care provider
developmentally-appropriate communication is critical.
and the patient is vital in treatment and management of
Often, information provided by a parent or caregiver prior
ADHD as well as collaboration with parents and often,
to the patient’s visit can assist greatly in preparation for the
teachers. To provide effective treatment, it is important
appointment. An attempt should be made to communicate
to: set specific and appropriate goals, start medicine and/
directly with the patient and, when indicated, to
or talk therapy, follow-up monthly with the dentist to re-
supplement communication with gestures and
check the goals, results, and any side effects of medicines
augmentative methods of communication during the
from the other health care provider. During these visits,
provision of dental care. At times, a parent, family member,
information should be gathered from the patient and if
or caretaker may need to be present to facilitate
relevant, parents and teachers.5
communication and/or provide information that the patient
The health care provider will likely confirm the person
cannot.7
has ADHD, to check the medical conditions that can cause
The presence or absence of the parent sometimes can
similar symptoms, make sure the treatment plan is being
be used to gain cooperation for treatment. There are
followed, medicine combined with behavioral treatment
different opinions for the parental presence / absence
often works best. There are several different ADHD
during a treatment procedure. Some prefer their presence
medicines that may be used alone or in combination.
as the parent may assist in behavior management. Some
The health care provider will decide which medicine
children behave well in the absence of their parents but
is right based on the person's symptoms and needs;
maybe untrue if the child is very young as the child may
psychostimulants are the most commonly used ADHD
prefer parental presence. The advantages of not allowing
medicines. Although these drugs are called stimulants, they
the parents in the operatory are: parents often repeat order,
actually have a calming effect on children with ADHD,
creating an annoyance for both dentist and child, the
follow the health care provider's instructions on how to
dentist is unable to use voice control in the presence of the
take ADHD medicine, because some ADHD medicines
parent because the parent may be offended, and the
have side effects. If the person has side effects, contact the
children attention is divided between parent and the
health care provider right away. The dosage or medicine
dentist.8
itself may need to be changed.5
When dealing with children, both time and the
In the case of our patient, we start the treatment at 12
length of the appointment are important. Children cannot
pm and end it before 2 pm to make sure the interventions
sit in one position for longer time and their threshold
are done before his attention shifts and while he is still
of tolerance is very low. Children should not be given
in a good mood during the treatment. Around 10 to 15
appointment during their naptime or soon after emotional
minutes before the treatment starts, we allow him to play
experience such as birth of a sibling or death of someone
and then we start with the procedures. When he starts to
close. Cooperation can be difficult to secure and emotional
troll we stop the treatment for a while and let him play on
difficulties are likely to be encountered .8
his phone for about 10 minutes or go to the toilet. Most
Dentist’s skill and speed are needed during the
of the time, we also use the ‘reward system’ to manage his
treatment especially in children with special needs. The
behavior and reach the goal of the treatment.
dentist should perform his duties with dexterity, in a
We did not use any restraint during the first day of
preplanned manner or avoid wasting the attention span of
treatment and his parents always accompanied him and
an ADHD patient. A child can endure discomfort if they
helped the dental team. After his fourth visit, we asked
know it is soon going to end. 8
the parents to wait outside for the patient to build trust
between him and the dentist. Currently, the patient is more
COnCluSIOn
cooperative even without his parents to accompany him
inside the room during the treatment.
There are not many differences with orthodontic
treatment of children with and without ADHD. A

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partnership between children, parent or caregiver, and the

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dentist are very important, to improve the outcomes of the

prescribed treatment for the dental condition. In this case ReFeRenCeS
we decided to use behavioral shaping, reward system, and
1. Dai D, Wang J, Hua J, He H. Classification of ADHD children
consistency in implementing the rules during the treatment, through multimodal magnetic resonance imaging. Front Syst
and with every step of the procedures, the child is exposed Neurosci. 2012 Sep; 6:63.
to the instruments being used to lessen the child’s fear of 2. Rada R, Bakhsh HH, Evans C. Orthodontic care for the behavior-
challenged special needs patient. Spec Care Dentist. 2015 May-Jun;
the unknown, which is normal with children.9, 10
35(3):138-42.
Patients with ADHD need more time to adapt to new 3. Strock M, Jensen PA, Menvielle E, Vitiello B. Attention Deficit
environment and conditions, and also take more time for Hyperactivity Disorder. 2019. p. 1–49.
treatment to be done to them. Children diagnosed with 4. Graham P. Attention deficit hyperactivity disorder. The British
Psychological Society and The Royal College of Psychiatrists; 2018.
ADHD have more anxiety and hardly able to focus. For p. 15.
effective treatment and management, dentists need to finish 5. Hoseini BL, Abbasi MA, Moghaddam HT, Khademi G, Saeidi M.
the tasks, procedures, and interventions faster than normal. Attention Deficit Hyperactivity Disorder ( ADHD ) in Children : A
Short Review and Literature. Int J Pediatr. 2014; 12(4-3):445–52.
6. Baharara J, Hojjati M, Rasti H, Jamab MS. The Ratio of Second to
Patient Consent Fourth Digit Length (2D:4D) in Children with Autistic Disorder. Int
The patient has agreed to the publication of photos and J Pediatr. 2014 Nov; 2(4-2):5–11.
case, without mention of the patient's identity. 7. Management Of Dental Patients With Special Health Care Needs
[Internet]. 2019 [cited 2019 July]. p. 237–42. Available from: https://
www.aapd.org/research/oral-health-policies--recommendations/
Statement of Authorship management-of-dental-patients-with-special-health-care-needs/
All authors participated in data collection and analysis, 8. Rao A. Principles and Practice of Pedodontics, 3rd ed. Mangalore:
and approved the final version submitted. Jaypee Brothers Medical Publisher; 2012. p. 107–8.
9. Duggal M, Cameron A, Toumba J. Paediatric Dentistry at a Glance.
Wiley-Blackwell; 2012. p. 120.
Author Disclosure 10. Sinha S, Praveen P, Prathibha Rani S, Anantharaj A. Pedodontic
All authors declared no conflict of interest. Considerations in a Child with Attention Deficit Hyperactivity
Disorder : Literature Review and a Case Report. Int J Clin Pediatr
Funding Source Dent. 2018 May-Jun; 11(3):254–9.
None.

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