Dental Care Providers Attention Deficit Hyperactivity .

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Attention Deficit Hyperactivity Disorder: Knowledge and Perception ofDental Care ProvidersAbeer Al Nowaiser1, Heba Elkhodary1,2, Omar El Meligy1,3, Lana Shinawi4, Elham Asiri5,Shuroog Aldosari61Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia, 2Department ofPediatric Dentistry, Faculty of Dental Medicine (Girl’s Branch), Al Azhar University, Cairo, Egypt, 3Department of PediatricDentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Egypt, 4Department of Oral and MaxillofacialProsthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia, 5Department of Orthodontics, Faculty ofDentistry, King Abdulaziz University, Jeddah, Saudi Arabia, 6Department of Dentistry, Kind Fahad Armed Forces Hospital, Jeddah,Saudi ArabiaAbstractAim: The aim was to measure the level of perception and knowledge of dental care providers to Attention Deficit HyperactivityDisorder (ADHD) at King Abdulaziz University faculty of dentistry (KAUFD), Jeddah, Saudi Arabia. Materials and Methods:Three-part questionnaire with an explanatory method were mailed to 50 specialist pediatric faculty members and residents (Master,Doctorate degrees and Saudi Board) and 140 dental interns and externs. The first part of the questionnaire includes the participants’demographic information. The second part related to the participants previous clinical and educational experiences with ADHD andthe third part included questions related to the participants’ knowledge and management of ADHD. The respondents were asked tochoose only one choice from 3 choices (agree, disagree, I do not know). Results: Working experience was found to be a significantfactor (P 0.05) in relation to the background knowledge of the participants when comparing those with 10 years of workexperience to those with 1-3 years and 4-9 years work experience. Additionally, female participants had better knowledge than theirmale counterpart (p 0.001), as did married participants (p 0.007) and those who have children especially with regards to theadverse effects of drugs, oral health and dental management for ADHD patients (p 0.001, p 0.011, p 0.011). Interns also reportedsignificant differences than consultants (P 0.05) in their knowledge and general information about oral health and dentalmanagement for ADHD. Conclusion: The background knowledge among a sample of oral health care providers in KAUFD wasfound to be statistically and positively related to the work experience in terms of years of practice as well as the social anddemographic status of the participants.Key Words: Perception, Knowledge, Dental interns, ADHDIntroductionand “predominantly hyperactive" [11]. ADHD Symptomsmust be present for at least 6 months and be present prior toage 7 [5]. Medications most commonly prescribed includeshort- and long-acting psychostimulants. Patients who haveadverse effect or do not respond to the stimulants can betreated with adjunctive or alternative medications [12].Alternative or complementary treatments include chamomile,additive and/or sugar-free diets, valerian, kava-kava, gingkobiloba, ginseng, and multivitamin therapy [13]. Managementof ADHD with effective psychosocial treatments involvesparticipation of parents and teachers to change the social andphysical environments in order to alter or change behavior[14]. Preschool early intervention with parent training iseffective, [15] while the multimodal approach employing bothmedication and psychosocial therapies was reported to be themost promising in reducing the multiple symptoms of ADHD[16,17]. A study found that combination approach is moresatisfying for both parents and teachers [18].Attention Deficit Hyperactivity Disorder (ADHD) is the mostcommonly diagnosed neuro-developmental disease [1]. It is acomplex neurobiological disorder affecting children and ischaracterized by inattention and/or impulsivity andhyperactivity [2]. The etiology of ADHD is a combination ofmultiple risk factors includes: psychosocial, biological,environmental and genetic factors. However, the exact causeremains unclear [3]. Pure cases of ADHD are rare [4], andmostly associated with other developmental disorders such asautism spectrum disorders, learning disabilities, intellectualdisability and cerebral palsy [3]. According to the AmericanAcademy of Pediatrics, ADHD prevalence ranges from 4% to12% [5]. Further epidemiological studies on ADHD estimateda prevalence of 7.48 % in Egypt [6], 11.9% males and 8.5%females in Palestine, 9.4% in Qatar, 29.7% in United ArabEmirates [7] and 3.2% in Lebanon [8]. In Saudi Arabia, astudy was conducted in Assir region to explore the ADHDprevalence in primary schools in Saudi Arabia and the resultshowed that the overall rate of ADHD was 2.7% [9]. Anotherstudy showed higher prevalence of combined ADHD amongschoolboys in Dammam of 16.4% [7]. In Riyadh, ADHDprevalence of 25.5% was reported among patients whoattended a psychiatric clinic at a university hospital [10].Oral health problemsStudies have shown that children with ADHD had higherDMF or dmf scores compared to controls [19,20]. Some havereported xerostomia, as an adverse reaction tomethylphenidate [21,22] while others did not find any effectof methylphenidate on salivary flow rates: A study by Groomet al. [23] reported no difference in unstimulated salivaproduction between children with ADHD and controls, whileAccording to Diagnostic and Statistical Manual of MentalDisorders Fourth Edition (DSM-IV), ADHD is subdividedinto three subtypes: “Combined”, “Predominantly inattentive”Corresponding author: Omar El Meligy, Professor, Department of Pediatric Dentistry, Faculty of Dentistry, King AbdulazizUniversity, Jeddah, Saudi Arabia, Tel: 966557521584; E-mail: omeligy@kau.edu.sa1

OHDM- Vol. 16- No.2-April, 2017another study by Hidas et al. [20] found that all ADHDchildren had significantly lower salivary flow ratesunstimulated salivary flow rates with lower values amongthose on medication. Children with ADHD had significantlyhigher decayed, missing or filled and significantly higherdecayed surfaces in comparison with controls [24].questionnaire was mailed a follow up cover letter and thequestionnaire was sent again to remind non-respondents tocomplete and return the questionnaire.A modified questionnaire prepared or designed byHirfanoglu et al. [32] was used in the present study. Initially, afocus group was organized to test the questionnaire forcontent, clarity and validity. The final three-part questionnaireconsisted of 55 items.A preliminary study found that ADHD children had greaterdifficulty in learning and performing a variety of motor skills[25]. Another study reported that one-third of ADHD childrenhave motor coordination problems reported by parents andteachers [26] which affects everyday activities such as Toothbrushing and dressing. Others reported that children withADHD who were on prescribed medications had a higherprevalence of Bruxism than others, and 2.5 times the numberof worn teeth was reported among those taking stimulants[27]. Oral habits (such as bruxism and nail biting) are reportedto be less common in children with ADHD than the controls[28].The first part of the questionnaire included the participants’demographic information: name (optional), gender, academicdegree, year and place of graduation, job position, and maritalstatus and if they had children. The second part related to theparticipants previous clinical and educational experienceswith ADHD: did the participants receive proper education ortraining for treating patients with ADHD, did they everprovided treatment or like to provide dental care to individualswith ADHD as a part of their dental practice. The third partincluded questions related to the participants knowledge andmanagement of ADHD on the basis of DSM-IV diagnosticcriteria [11] to assess the general knowledge, differentialdiagnosis and coexisting conditions regarding ADHD. Themedical management and adverse effects of drugs, oral healthproblems and dental management of ADHD was alsoevaluated.Dental managementBehavioral management is one of the more challengingaspects in treating children with ADHD; due to their inabilityto stay focused on the dental treatment. It is always useful toconsult the patient's pediatrician and/or other health careproviders. Careful timing of appointments is important, withscheduling those in the morning usually advisable [29].Atmetlla et al. [28] showed that it’s more difficult to managechildren with ADHD in the dental office due to difficulty inestablishing communication, especially with oral hygieneinstruction. "Tell-show-do" was the most effective behaviormanagement technique of choice because it moderates thebehavior of ADHD children [30]. Despite the vast amount ofresearch on ADHD, there are still concerns regardingidentification, referral, diagnosis and treatment of childrenwith ADHD. This is highly influenced by the knowledge andperspectives of all individuals involved. Diagnosis andtreatment of ADHD requires the collaboration between thefamily, the educational sector and the health care professionals[31]; therefore, it is essential to address such variance in orderto attain a mutual understanding and common goals.The questionnaire included 4 questions on the backgroundinformation about ADHD, 42 questions addressed generalknowledge and management of ADHD by dental practitioners(general knowledge questions were 12, differential diagnosisquestions were 6, coexisting conditions questions were 4, themedical management and adverse effects of drugs questionswere 6, oral health problems questions were 8 and dentalmanagement questions were 6). The answers included 3choices: agree, disagree, I do not know.Statistical analysisStatistical Package for the Social Sciences (SPSS) 10.0 wasused. The numerical values, age of the doctors and the time ofresidency were expressed as mean standard deviation (SD).Chi-square analysis was used in testing the differencesbetween physician responses according to their institution(UH or SH), and private office. Overall assessment of eachdivision was carried using the independent t test.AimThe aim of the current study is to measure the level ofperception and knowledge of dental care providers to ADHD.ResultsMaterials and MethodsOf the health care providers participating in our study 57.9%were female and 42.1% were male. 57.2% of the participantswere married and 42.8% were single. Those with childrenwere only 25.2% while 74.8% did not have children. Most theparticipants (83.6%) were holders of bachelor degree of dentalsurgery while 11.3% were enrolled in master degree (MSc) orSaudi board holders and only 5% were awarded withdoctorate degree (PhD). About 74.8% of the respondents wereinterns, 16.4% were pediatric dentistry residents and 8.8%were consultant pediatric dentists. 5% of the participants hadbeen working for 10 years and above (10 years), 13.2% forA cross-sectional observational study at KAUFD in Jeddah,Saudi Arabia was conducted. The Ethical Committee atKAUFD approved the research protocol. Two appropriatesamples were chosen for the study group as follows: 50specialist pediatric faculty members and residents (MSc, PhDand Saudi Board) as well as 140 dental interns and externswere included in the study. All participants were fromKAUFD. Questionnaires with an explanatory method weremailed to them. The participants were informed about thestudy and assured of anonymity. Two weeks after the2

OHDM- Vol. 16- No.2-April, 20174-9 years, while 78.6% for only 1-3 years. These demographiccharacteristics are shown in (Table 1).Table 1. The characteristics of the health care providers.Characteristics of the health care providers (N HD85Intern11974.8Pediatric Dentistry Residents2616.4Consultants pediatric dentists148.81-312578.64-92113.210 and above85GenderMarital statusHaving childrenAcademic degreeOccupationYears of experienceHealth care providers background information towardsADHDreported that they didn’t receive proper training for treatingpatients with ADHD. Almost all the respondents (C: 100.0%,R: 96.2% and I: 68.1%) reported that they are willing toprovide dental care to individuals with ADHD as a part oftheir dental practice. There is a gradient statisticallysignificant decrease in the percentage of agreement andwillingness to provide dental care to individuals with ADHDfrom consultants down to residents then interns (p 0.001)(Table 2).Most participants (Interns (I): 86.6%, Pediatric DentistryResidents (R): 61.5%, Consultant Pediatric Dentists (C): 42.9)have never provided treatment for a patient with ADHD. Mostof the consultants (71.4%), half of the residents (46.2%) and14.3% of the Interns have received proper education toeffectively treat individuals with ADHD. About 50% of theconsultants, 76.9% of the residents and 95.0% of the InternsTable 2. Health care providers background information towards ADHD.OccupationHaveyoueverprovided treatment fora patient with ADHD?Did you receive theproper education toeffectivelytreatindividualswithADHD?Did you receive theproper training fortreating patients withADHD?Would you like toprovide dental care toindividualswithPediatric Dentistry Residents(n 26)Interns (n 119)Background InformationP valueConsultant Pediatric Dentists(n 100 0.001* 0.001* 0.001* 0.001*3

OHDM- Vol. 16- No.2-April, 2017ADHD as a part ofyour dental practice?Relation between health care providers backgroundinformation towards ADHD and their years of workingexperiencetraining for treating patients with ADHD, nearly 62.5% ofthose with more years of experience (10 years) reported thatthey received proper education and 37.5% of the same groupreceived further training. The rate was significantly differentthan those with 1-3 years and 4-9 years of working experience(Table 3).No significant differences were reported regarding providingtreatment for ADHD patients or to their likeness to providedental care to individuals with ADHD as part of their practice.When questioned regarding proper education or properTable 3. Relation between health care providers background information towards ADHD and their years of experience.Years of experienceBackground Information1-3 years (n 125)P value4-9 years (n 21)10 years (n 8)n%n%n%Haveyouever Noprovided treatment fora patient with ADHD? Yes10382.41466.7562.52217.6733.3337.5Did you receive the Noproper education toeffectivelytreatindividualswith YesADHD?100801571.4337.52520628.6562.5Did you receive the Noproper training fortreating patients withYesADHD?11491.21990.5562.5118.829.5337.5Would you like to Noprovide dental care toindividuals with ADHDas a part of your Yesdental practice?3427.2314.3009172.81885.781000.126 NS0.019*0.036*0.116 NS* Statistically significant at P 0.05. NS: Not statistically significant.Health care providers demographics compared withknowledge, attitude and conceptions of ADHDresidents and consultants (p 0.022, p 0.001). Interns alsoreported significantly lower differences than consultants(p 0.004) in the general information about ADHD’s oralhealth. When questioning their knowledge about dentalmanagement for ADHD, interns showed again significantlower differences than consultants (p 0.004) (Table 4).When comparing the scores relating to knowledge, attitudeand conceptions about ADHD to the demographics ofparticipants; mixed results were obtained. There wasstatistical significant difference between the responses givenby females and males, where females had superior knowledgeregarding ADHD’s oral health and management compared tomales (p 0.001). Also, married participants showedsignificantly greater knowledge with regards to oral healthand ADHD than single participants (p 0.007) and those whohave children reported statistically significant betterinformation about adverse effects of drugs, oral health anddental management for ADHD patients (p 0.001, p 0.011,p 0.011). There were differences between responses given byconsultants, residents and interns regarding knowledge,attitude, conceptions and management of ADHD. Internsshowed significantly less knowledge about ADHD thanresidents and consultants (p 0.07 and p 0.002). For the coexistent conditions and adverse effects of drugs, interns againreported lower knowledge significantly compared to bothDiscussionThe present cross-sectional observational study is one of therecent studies to measure the level of perception andknowledge of dental care providers to ADHD at KAUFD,Jeddah, Saudi Arabia. It was intended to assess the knowledgeand general information of specialist pediatric facultymembers, residents and dental interns about oral health anddental management for ADHD.ADHD is a common psychiatric disorder that ischaracterized by symptoms of inattention, impulsivity, andhyperactivity [2]. The overall prevalence of ADHD in SaudiArabia varies among the different regions of the Kingdomwith some areas reporting high prevalence. Accordingly, thelevel of knowledge and understanding of the disease must be4

OHDM- Vol. 16- No.2-April, 2017addressed and shared with all practitioners, parents, teachers,and healthcare providers.Table 4. Correlation between health care providers demographics with knowledge, attitude and conceptions of ADHD.NManagementandOralhealthadverse effects ofADHDdrugsCo-existentconditionsandDental managementKnowledgeADHDabout dMinMaxMedMinMaxMedMinMaxfor 04106307307P-value0.110 NS0.687 NS0.084 NS0.890 NS 0.001* 0.001*Marital 5040053.5063.506P-value0.203 NS0.463 NS0.934 NS0.097 NS0.007*0.007*Having 07407P-value0.411 NS0.212 NS0.067 b04006407407P-value 0.001*0.079 NS0.010* 0.001*0.001*0.001*Yearsofexperience1-3 years12550102061040064074074-9 years2161920630420650750710 years85381041043055265260.076 NS0.395 NS0.001*0.002*0.014*0.014** Statistically significant at P 0.05. NS: Not statistically significant.A study in the USA [33] with a sample size of 374adolescents at risk of ADHD and their caregivers who thoughtthey had perfect knowledge about the disease revealed theopposite as indicated by their answers to the questioner.Another study in the USA [34] compared teacher trainees’knowledge of ADHD with that of undergraduate students andfound that teacher trainees showed good actual and perceivedknowledge which was significantly higher than undergraduatestudents. Similarly, a survey of 3,409 pediatricians and familyphysicians working in Canada [35] reported referral of ADHDpatients to other professionals as they lack the requiredknowledge to manage them.ascertain whether the participants received the propereducation and training to effectively treat individuals withADHD. According to the results of this study, there is astatistically significant decrease in the percentage ofagreement and willingness to provide dental care toindividuals with ADHD that is a gradient (from consultantsdown to residents then interns). Hence educational courses areneeded combined with further training in order to increase theability to manage and enhance the knowledge of oral healthcare providers. A study conducted in Turkey by Hirfanoglu etal. [32] reported that approximately 102 (65.3%) of theresidents stated right answers to the questions duringevaluating their knowledge of ADHD, 127 thought that theirknowledge of ADHD was insufficient, while 123 stated thatthey did not even know how to diagnose th

Attention Deficit Hyperactivity Disorder: Knowledge and Perception of Dental Care Providers Abeer Al Nowaiser1, Heba Elkhodary1,2, Omar El Meligy1,3, Lana Shinawi4, Elham Asiri5, Shuroog Aldosari6 1Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia, 2Department of Pediatric Dentistry, Faculty of Dental Medicine (Girl’s Branch), Al Azhar .

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