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J Am Dent Assoc, Vol 138, No 4, 475-482.
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CLINICAL PRACTICE

JADA Continuing Education

The pathophysiology, medical management and dental implications of adult attention-deficit/hyperactivity disorder

Arthur H. Friedlander, DMD, John A. Yagiela, DDS, PhD, Michael E. Mahler, MD and Robert Rubin, MD


   ABSTRACT
TOP
 ABSTRACT
ATTENTION-DEFICIT/HYPERACTIVITY...
 MEDICAL MANAGEMENT
 DENTAL MANAGEMENT IMPLICATIONS
 CONCLUSION
 REFERENCES
 
Background. Few published reports in the dental literature have focused on adult attention-deficit/hyperactivity disorder (ADHD) and its dental implications.

Types of Studies Reviewed. The authors conducted a MEDLINE search for the period 2000 through 2005 using the terms "adult" and "attention-deficit" to define ADHD’s pathology, medical treatment and dental implications.

Results. ADHD is a developmental condition that affects slightly more than 4 percent of the adult U.S. population. Its symptoms include inattention, hyperactivity and impulsivity that can cause personal, social, occupational and leisure-time dysfunction. Medications used to treat the disorder include stimulants, selective noradrenergic uptake inhibitors and tricyclic antidepressants.

Clinical Implications. The oral health of people with ADHD may be compromised by inattention and impulsivity that impair home care regimens and can lead to cigarette addiction, which may cause oral cancer and damage the periodontium, and excessive ingestion of caffeinated sugar-laden soft drinks that promote dental caries. To safely care for this patient population, dentists must be familiar with the stimulant and nonstimulant medications used to treat adult ADHD, because these drugs can cause adverse orofacial and systemic reactions and interact adversely with dental therapeutic agents.

Key Words: Attention-deficit/hyperactivity disorder; drug interactions; attention; dental care for disabled

Abbreviations: ADHD: Attention-deficit/hyperactivity disorder • CNS: Central nervous system • TCAs: Tricyclic antidepressants

Few published reports in the dental literature have focused on adult attention-deficit/hyperactivity disorder (ADHD) and its dental implications. Therefore, we conducted a MEDLINE search for the period 2000 through 2005 using the terms "adult" and "attention-deficit" to define the disorder’s pathology, medical treatment and dental implications.


   ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
TOP
 ABSTRACT
 ATTENTION-DEFICIT/HYPERACTIVITY...
MEDICAL MANAGEMENT
 DENTAL MANAGEMENT IMPLICATIONS
 CONCLUSION
 REFERENCES
 
ADHD is a neurodevelopmental disorder that usually is evident in people younger than 7 years and can continue throughout life. In adults, it is characterized by a persistent pattern of inattention, restlessness and impulsivity that impairs day-to-day vocational, social and family functioning.1

Inattention frequently presents as a short attention span that prevents the person from focusing continuously on verbal and written instructions, resulting in difficulties in learning new tasks and the commission of careless mistakes.2 To some, it may appear that the person is simply daydreaming. People with ADHD often avoid advanced educational and employment opportunities because of their inability to mount sustained mental effort and because they have difficulty organizing tasks and finishing projects. In social situations, they are distracted easily during conversations and activities and often are forgetful (for example, missing appointments and misplacing and losing items that are necessary for the activities of daily living).

Restlessness may reflect an internal sense of anxiety and nervousness, which hinders people’s ability to unwind and relax and exacerbates their inattention (for example, being unable to sit at a desk for long periods or sit through a movie). Restlessness is evident as people with ADHD fidget (for example, persistent pencil tapping, foot tapping or both) and lead chaotic lifestyles (for example, attempting to work two jobs with long hours).3

Impulsivity makes it difficult for people with ADHD to wait their turns and can lead to interrupting others when they are busy and finishing the sentences of others with whom they are speaking. Impulsive actions that also commonly occur include excessive spending of money, frequent job changes and traffic violations (for example, speeding, running red lights).4

Stress, unstructured environments, group situations or demands for complex performance usually exacerbate attention-deficit/hyperactivity disorder symptoms.

Stress, unstructured environments, group situations or demands for complex performance usually exacerbate ADHD symptoms. Many adults with ADHD are not cognizant of their deficits and have little insight into them. Family relationships often suffer because other family members believe that the behaviors associated with ADHD are being done on purpose or are merely signs of laziness.5

A diagnosis of ADHD is made based on an assessment of the patient’s symptoms, as well as establishing that the symptoms began in childhood, possibly in a modified form. To help the clinician define the patient’s problems, a symptom checklist or standardized rating scale such as the Brown Attention-Deficit Disorder Scale for Adults6 or the Conners’ Adult ADHD Rating Scales7 should be used. The Wender Utah Rating Scale often is employed to diagnose the onset of the disorder during childhood retrospectively.8 The clinician also should take a medical, educational, social, psychological and vocational history. To arrive at the diagnosis, the clinician also must exclude the other psychiatric disorders that often accompany ADHD and complicate its diagnosis.9 No specific neuropsychological test, brain scan or blood test can diagnose ADHD reliably.

Epidemiology and associated disorders. ADHD affects 4 to 9 percent of school-aged children and persists into adulthood, with significant symptomatology in approximately 40 to 65 percent of these people.10,11 Therefore, approximately 4.4 percent of the adult U.S. population has the disorder.12,13 ADHD initially was thought to affect boys three times more frequently than it did girls. It is recognized, however, that this discrepant sex ratio probably arises because boys with the disorder are more likely to exhibit disruptive behavior patterns and learning disabilities than are girls and, therefore, are more likely to be referred for treatment.14–16 Adults almost always self-refer for treatment; this often occurs when their children are diagnosed with the disorder, and they recognize for the first time that they also might have the illness.17 The sex distribution of self-referring adults is nearly equal.18

Adults who have the disorder, especially those with associated learning problems (for example, difficulty performing tasks requiring vigilance, organization, planning, complex problem-solving ability, verbal learning and memory), tend to drop out of college or not complete a vocational course of study.19–22 These deficits also are believed to be responsible for work-related difficulties, frequent job changes, lower socioeconomic status, and high rates of spousal separation and divorce.23,24

More than one-half of adults with ADHD have a concurrent psychiatric disorder; 19 to 37 percent have mood disorders (for example, major depressive disorder, bipolar disorder or dysthymia), 25 to 50 percent have anxiety disorders, and 32 to 53 percent are addicted to illicit drugs.25,26 For the latter, cocaine often is the drug of choice, and it might represent a person’s attempt to self-medicate, because the drug, which has similar actions to the stimulant medications used to treat the illness, appears to ameliorate the symptoms of ADHD.27–29

Genetics and etiology. The cause of ADHD remains unknown, though most hypotheses focus on an abnormal brain function of genetic origin. The monozygotic (identical) twin of a child with ADHD has a greater than 90 percent chance of having the disorder, and 57 percent of children born to a parent with ADHD also develop the disorder.30,31 Evidence for the involvement of the dopamine D4 receptor gene is compelling, because a variant form of it leads to a blunted response to the neurotransmitters dopamine and norepinephrine and an imbalance of these neuro-transmitters in the frontal lobes of the brain is believed to be responsible for such symptoms as inattention, lack of alertness, and impaired organization and planning.32,33 The administration of stimulants and certain tricyclic antidepressants (TCAs) appears to increase the activities of these neurotransmitters in the brain, thereby ameliorating these symptoms.34,35

Structural and functional brain-imaging studies and neurocognitive testing of people with ADHD have identified abnormalities in the frontal lobes, basal ganglia, corpus callosum and cerebellum. These abnormalities are believed to be responsible for the deficits in executive function that underlie ADHD.36–38 Executive function includes the ability to sustain focus and filter out irrelevant and distracting stimuli; switch attention from one source of information to another; and plan, organize and monitor thoughts and working memory (that is, the ability to temporarily hold information in mind, manipulate it and use it to guide behavior).39,40 The administration of stimulant medications appears to activate areas of the brain involved in executive function, thereby ameliorating ADHD symptoms.41


   MEDICAL MANAGEMENT
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 ABSTRACT
 ATTENTION-DEFICIT/HYPERACTIVITY...
 MEDICAL MANAGEMENT
DENTAL MANAGEMENT IMPLICATIONS
 CONCLUSION
 REFERENCES
 
Management of ADHD consists of educating the patient and his or her family about the disease and treatment options, which almost always include pharmacotherapy and behavioral therapy. Medications useful for treating ADHD in adults include stimulants, noradrenergic uptake inhibitors and TCAs (Table 1Go).42


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  		TABLE 1 Drugs commonly used to treat attention-deficit/hyperactivity disorder and their adverse systemic side effects and interactions with dental therapeutics.*

 
The stimulant medications methylphenidate, amphetamine and dextroamphetamine are used most commonly and are highly effective in a dose-dependent manner.43 These medications evoke the release of dopamine and norepinephrine from adrenergic nerve terminals and block their uptake into the presynaptic neuron, thereby increasing the active concentrations of these neurohormones in the synaptic clefts in the brain stem, midbrain and frontal cortex. The clinical effect is improved attention span and concentration ability and reduced hyperactivity and impulsivity.44 The stimulant drugs also improve cognitive performance (for example, short-term memory, reaction time, math computation, problem solving and task persistence), fine motor speed, coordination, social interactions and peer relations. Side effects include elevations in systolic and diastolic blood pressure and pulse rate and an increased risk of experiencing myocardial infarction and cerebrovascular accident.45

Atomoxetine, a nonstimulant medication, specifically inhibits presynaptic norepinephrine uptake, resulting in an accumulation of norepinephrine in the synaptic cleft and consequent improvement in all three of the core symptoms of ADHD in adults: inattention, hyperactivity and impulsivity. This drug also is useful in addressing mood and anxiety disorders associated with ADHD, but is associated with an increased risk of experiencing suicidal ideation, increased blood pressure and pulse, decreased appetite, weight loss, fatigue and sleep disturbances.46

TCAs and bupropion are prescribed to those who do not respond to the stimulants or atomoxetine, who experience unacceptable side effects, or who have severe concomitant disorders such as depression, anxiety or a tic disorder.47 The TCAs have proved most effective, specifically those that also increase concentrations of norepinephrine in the synaptic cleft by inhibiting its uptake by the presynaptic neuron (for example, desipramine and imipramine). These medications are particularly effective in relieving inattention and hyperactivity, but they may not address impulsivity. Use of TCAs, especially imipramine, is associated with significant anticholinergic effects (for example, xerostomia and constipation) and postural hypotension.48,49 The atypical antidepressant bupropion also is used to treat ADHD and is especially effective in relieving inattention and hyperactivity, as well as aberrant mood and cigarette smoking, but not impulsivity.50,51 Bupropion’s therapeutic effect comes from its ability to increase the concentrations of norepinephrine and dopamine in the synaptic cleft. The principal dose-dependent toxic effect of bupropion is stimulation, which may lead to anxiety, agitation and seizures. Other side effects of bupropion include fatigue, xerostomia, insomnia, headaches, nausea, vomiting, constipation and skin rash.52

Behavioral/psychosocial treatment for adults with ADHD usually are offered to the 20 to 30 percent of patients who do not adequately respond to medication and to those who must discontinue medication use because of significant side effects. This nonpharmacological form of treatment provides patients with concrete strategies and skills for coping with their impairments and is geared toward organizational management and interpersonal relationships. A time-management program often is implemented that teaches the person to plan and organize the next day’s activities, as well as to identify short- and long-term goals. People with ADHD also are taught to use appointment books, daily planning calendars and personal digital assistants to avoid missing important meetings. Marital and family therapy and social skills training help patients overcome interpersonal difficulties with spouses (for example, complaints that the patient is forgetful, unreliable and a poor listener) and coworkers (for example, complaints of poor follow-through on commitments).53,54


   DENTAL MANAGEMENT IMPLICATIONS
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 ABSTRACT
 ATTENTION-DEFICIT/HYPERACTIVITY...
 MEDICAL MANAGEMENT
 DENTAL MANAGEMENT IMPLICATIONS
CONCLUSION
 REFERENCES
 
Providing comprehensive dental care to adults receiving treatment for ADHD usually requires only minimal modification, because the patients’ behavior in the dental office often does not differ significantly from people who do not have ADHD. It is best, however, to schedule dental appointments in the morning when people with ADHD are least fatigued, most attentive and best able to remain seated in the dental chair. Morning appointments also are appropriate because most medication regimens are designed for the maximum drug effect (enhanced cognition and behavior) to occur during the early part of the workday. The dental team must remember, however, that tardiness, missed appointments, failure to return insurance forms, barging in without an appointment and breaking into a rage if kept waiting may be signs of the disorder.

Obtaining a comprehensive medical history, including use of illicit substances, is crucial when treating adults with ADHD because their risk of experiencing substance abuse is substantial.55 Given the stigma associated with substance abuse, however, patients rarely disclose this information to their dentists. Similarly, dentists may be reluctant to delve into the issue of substance abuse, because it may seem intrusive or because they view the addiction as a moral shortcoming rather than as a valid medical disorder. This avoidance presents a danger because of the effects of illicit drug use on oral and systemic health and because of an enhanced risk of the patient’s experiencing medication-related adverse events and drug interactions. Dentists who believe that a patient may be abusing potentially harmful substances should discuss the issue with the patient and obtain his or her informed consent to refer the patient to a primary care physician, psychiatrist or psychologist.

During the clinical examination, minor physical abnormalities such as hypertelorism, high-arched palate and low-set ears may be identified. These abnormalities have been noted, but the prevalence of these abnormalities has not been determined.56 There may be the presence or history of orofacial injury, given the propensity of people with ADHD to be involved in automobile accidents owing to inattention, impulsive behavior, and impaired reaction time, visual-motor coordination, decision making and rule-governed behavior.57

There may be the presence or history of orofacial injury, given the propensity of people with attention-deficit/hyperactivity disorder to be involved in automobile accidents.

Some adults with ADHD self-medicate by smoking cigarettes, possibly because nicotine receptors modulate dopaminergic activity, thereby improving cognitive performance and decreasing inattention and distractibility.58–60 Smoking, however, is associated with the development of oral cancer and periodontal disease.61 People with ADHD also frequently consume excessive amounts of caffeine-containing beverages to improve their cognitive abilities.62,63 Such beverages can stain the teeth and, if they contain sugar, can contribute to caries formation.64,65 Dental health may be further compromised by the inability of people with ADHD to comply fully with home-care regimens, because of inattention and impulsivity and because of the adverse effects of the medications used to treat the disorder.

Many of the drugs used to treat ADHD have adverse orofacial side effects (Table 1Go).66,67 The stimulants methylphenidate, amphetamine and dextroamphetamine may cause xerostomia, and use of the latter two medications are associated with loss of smell and taste acuity.68 Atomoxetine has been shown to cause xerostomia and sinusitis.69 The antidepressants desipramine, imipramine and bupropion may cause xerostomia and dysgeusia.

The medications used to treat ADHD also can cause adverse interactions with drugs used in dentistry (Table 2Go).70–73 As we mentioned previously, methylphenidate, amphetamine and dextroamphetamine are associated with elevations in blood pressure and heart rate. Prudent care includes scheduling these patients for early morning appointments, requesting that they delay their morning doses of medication until after the dental appointment and, as clinically necessary, taking and recording the patient’s pre-operative vital signs and intraoperative values. Obtaining profound local anesthesia, which will limit pain and the endogenous production of catecholamines that might interact with these agents, is mandatory. Moreover, an aspirating syringe must be used to avoid intravascular injection and the possibility of a summation of drug effects from the vasoconstrictor agents (epinephrine, levonordefrin) used in local anesthesia. It also is important initially to administer no more than 1 microgram per kilogram of epinephrine up to a maximum of 40 µg (as is found in two cartridges of 2 percent lidocaine with 1:100,000 epinephrine). If the patient’s vital signs remain stable, additional anesthetic may be administered.


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  		TABLE 2 Adverse orofacial reactions to drugs used to treat attention-deficit/hyperactivity disorder.*

 
The stimulants amphetamine and dextroamphetamine may block monoamine oxidase activity and adversely interact with meperidine to produce fever, hypotension and even respiratory collapse. These stimulants also may interact with large doses of propoxyphene, producing excessive CNS stimulation and seizure activity.

The TCAs desipramine and imipramine block the uptake of adrenergic vasoconstrictors (for example, levonordefrin and epinephrine) that are compounded with many local anesthetic agents, thereby prolonging their action. They also block muscarinic and alpha 1–adrenergic receptors, which can increase the heart rate and relax the peripheral vasculature, respectively. Prudence dictates that patients receiving either of these two TCAs should not be administered a local anesthetic agent containing levonordefrin, as cardiac dysrhythmias and a dramatic increase in systolic blood pressure might follow, especially after an accidental intravascular injection. Epinephrine interacts with TCAs more modestly so that it can be used in reduced doses (for example, up to a maximum of three cartridges per half hour) and with careful aspiration to avoid intravascular administration.74 Because atomoxetine also blocks the uptake of norepinephrine, the same restriction on vasoconstrictors used for the TCAs should be followed until more is known about the drug’s potential for this interaction.

Patients with ADHD smoke cigarettes at an average rate twice that of people who do not have ADHD.75 However, patients who smoke and are being treated with TCAs should not be prescribed bupropion (which is used to help with smoking cessation) by the dentist without medical consultation, because the seizure threshold is decreased when these medications are used together. Instead, counseling and other nonpharmacological smoking cessation approaches should be instituted for these patients.

Other adverse drug interactions between TCAs and medications used in dentistry also can produce significant morbid reactions. The depressant effects of sedative-hypnotic drugs, antianxiety drugs and opioids may be increased by TCAs, and respiratory depression may ensue. The administration of drugs with anticholinergic properties such as atropine or scopolamine can cause an increase in intraocular pressure and worsen occult or known narrow-angle glaucoma.


   CONCLUSION
TOP
 ABSTRACT
 ATTENTION-DEFICIT/HYPERACTIVITY...
 MEDICAL MANAGEMENT
 DENTAL MANAGEMENT IMPLICATIONS
 CONCLUSION
REFERENCES
 
The medical management of ADHD brings about a 50 to 75 percent reduction in symptomatology. Therefore, dentists must not misconstrue inattention, motor restlessness, broken appointments and an inability to complete home-care tasks as simple noncompliance, but rather as a potential component of a disorder requiring understanding, compassion and implementation of special management techniques. In consultation with the physician treating the patient’s ADHD, the full range of dental procedures can be provided to people with ADHD.


   FOOTNOTES
 

Dr. Friedlander is associate chief of staff and the director of Graduate Medical Education, VA Greater Los Angeles Healthcare System, the director of Quality Assurance, Hospital Dental Service, University of California Los Angeles Medical Center, and a professor of Oral and Maxillofacial Surgery, University of California Los Angeles School of Dentistry. Address reprint requests to Dr. Friedlander at VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, Calif. 90073, e-mail "arthur. friedlander{at}med.va.gov".


Dr. Yagiela is a professor and the chair, Diagnostic and Surgical Sciences, University of California Los Angeles, School of Dentistry, and a professor of anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles.


Dr. Mahler is the director of quality improvement, and an attending neurologist, Neurobehavior Clinic, VA Greater Los Angeles Healthcare System, Los Angeles, and a clinical professor of neurology, David Geffen School of Medicine at UCLA, Los Angeles.


Dr. Rubin is the chief, Department of Psychiatry and Mental Health, VA Greater Los Angeles Healthcare System, and a professor and the vice-chair, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles.


   REFERENCES
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 ABSTRACT
 ATTENTION-DEFICIT/HYPERACTIVITY...
 MEDICAL MANAGEMENT
 DENTAL MANAGEMENT IMPLICATIONS
 CONCLUSION
 REFERENCES
 

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington: American Psychiatric Association; 1994:85–93.

  2. Seidman LJ, Doyle A, Fried R, Valera E, Crum K, Matthews L. Neuropsychological function in adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 2004;27(2):261–82.[Medline]

  3. Adler L, Cohen J. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 2004;27(2):187–201.[Medline]

  4. Barkley RA. Driving impairments in teens and adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 2004;27(2):233–60.[Medline]

  5. Wender PH, Wolf LE, Wasserstein J. Adults with ADHD: an overview. Ann N Y Acad Sci 2001;931:1–16.[Medline]

  6. Brown TE. Brown attention-deficit disorder scales. San Antonio: Psychological Corp.; 1996.

  7. Conners CK, Erhardt D, Sparrow E. Conners’ adult ADHD rating scales: Technical manual. North Tonawanda, N.Y.: Multi-Health Systems; 1999.

  8. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 1993;150(6):885–90.[Abstract/Free Full Text]

  9. Murphy KR, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiatry 2004;65(supplement 3):12–7.

  10. Adler LA. Clinical presentations of adult patients with ADHD. J Clin Psychiatry 2004;65(supplement 3):8–11.[Medline]

  11. Barkley RA, Fischer M, Smallish L, Fletcher K. Young adult outcome of hyperactive children: adaptive functioning in major life activities. J Am Acad Child Adolesc Psychiatry 2006;45(2):192–202.[Medline]

  12. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006;163(4):716–23.[Abstract/Free Full Text]

  13. Faraone SV, Spencer TJ, Montano CB, Biederman J. Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care. Arch Intern Med 2004;164(11):1221–6.[Abstract/Free Full Text]

  14. Biederman J, Faraone SV, Monuteaux MC, Bober M, Cadogen E. Gender effects on attention-deficit/hyperactivity disorder in adults, revisited. Biol Psychiatry 2004;55(7):692–700.[Medline]

  15. Murphy K, Barkley RA. Prevalence of DSM-IV symptoms of ADHD in adult licensed drivers: implications for clinical diagnosis. J Atten Disord 1996;1(3):147–61.[Abstract]

  16. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult outcome of hyperactive boys: educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry 1993;50(7):565–76.[Abstract/Free Full Text]

  17. Michelson D, Adler L, Spencer T, et al. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry 2003;53(2):112–20.[Medline]

  18. Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annu Rev Med 2002;53:113–31.[Medline]

  19. Barkley RA. Major life activity and health outcomes associated with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2002;63(supplement 12):10–5.

  20. Spencer TJ, Biederman J, Wilens TE, Faraone SV. Overview and neurobiology of attention-deficit/hyperactivity disorder. J Clin Psychiatry 2002;63(supplement 12):3–9.

  21. Heiligenstein E, Conyers LM, Berns AR, Miller MA. Preliminary normative data on DSM-IV attention deficit hyperactivity disorder in college students (published correction appears in J Am Coll Health 1998;46[5]:213). J Am Coll Health 1998;46(4):185–8.[Medline]

  22. Hervey AS, Epstein JN, Curry JF. Neuropsychology of adults with attention-deficit/hyperactivity disorder: a meta-analytic review. Neuropsychology 2004;18(3):485–503.[Medline]

  23. Murphy K, Barkley RA. Attention deficit hyperactivity disorder adults: comorbidities and adaptive impairments. Compr Psychiatry 1996;37(6):393–401.[Medline]

  24. Brod M, Johnston J, Able S, Swindle R. Validation of the adult attention-deficit/hyperactivity disorder quality-of-life Scale (AAQoL): a disease-specific quality-of-life measure. Qual Life Res 2006;15(1): 117–29.[Medline]

  25. Kates N. Attention deficit disorder in adults: management in primary care. Can Fam Physician 2005;51:53–9.[Abstract/Free Full Text]

  26. Biederman J, Monuteaux MC, Mick E, et al. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med 2006;36(2):167–79.[Medline]

  27. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry 1993;150(12):1792–8.[Abstract/Free Full Text]

  28. Biederman J, Wilens T, Mick E, Milberger S, Spencer TJ, Faraone SV. Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity. Am J Psychiatry 1995;152(11):1652–8.[Abstract/Free Full Text]

  29. Wilens TE. Impact of ADHD and its treatment on substance abuse in adults. J Clin Psychiatry 2004;65(supplement 3):38–45.[Medline]

  30. Faraone SV. Genetics of adult attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 2004;27(2):303–21.[Medline]

  31. Biederman J, Faraone SV, Mick E, et al. High risk for attention deficit hyperactivity disorder among children of parents with childhood onset of the disorder: a pilot study. Am J Psychiatry 1995;152(3):431–5.[Abstract/Free Full Text]

  32. Lanau F, Zenner MT, Civelli O, Hartman DS. Epinephrine and norepinephrine act as potent agonists at the recombinant human dopamine D4 receptor. J Neurochem 1997;68(2):804–12.[Medline]

  33. Larisch R, Sitte W, Antke C, et al. Striatal dopamine transporter density in drug naive patients with attention-deficit/hyperactivity disorder. Nucl Med Commun 2006;27(3):267–70.[Medline]

  34. Biederman J. Attention-deficit/hyperactivity disorder: a selective overview. Biol Psychiatry 2005;57(11):1215–20.[Medline]

  35. Wilens TE, Spencer TJ, Biederman J. A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder. J Atten Disord 2002;5(4):189–202.[Medline]

  36. Seidman LJ, Valera EM, Makris N. Structural brain imaging of attention-deficit/hyperactivity disorder. Biol Psychiatry 2005;57(11):1263–72.[Medline]

  37. Hesslinger B, Tebartz van Elst L, Thiel T, Haegele K, Hennig J, Ebert D. Frontoorbital volume reductions in adult patients with attention deficit hyperactivity disorder. Neurosci Lett 2002;328(3):319–21.[Medline]

  38. Zametkin AJ, Nordahl TE, Gross M, et al. Cerebral glucose metabolism in adults with hyperactivity of childhood onset. N Engl J Med 1990;323(20):1361–6.[Abstract]

  39. Schweitzer JB, Lee DO, Hanford RB, et al. Effect of methylphenidate on executive functioning in adults with attention-deficit/hyperactivity disorder: normalization of behavior but not related brain activity. Biol Psychiatry 2004;56(8):597–606.[Medline]

  40. Roth RM, Saykin AJ. Executive dysfunction in attention-deficit/hyperactivity disorder: cognitive and neuroimaging findings. Psychiatr Clin North Am 2004;27(1):83–96.[Medline]

  41. Riordan HJ, Flashman LA, Saykin AJ, Frutiger SA, Carroll KE, Huey L. Neuropsychological correlates of methylphenidate treatment in adult ADHD with and without depression. Arch Clin Neuropsychol 1999;14(2):217–33.[Abstract/Free Full Text]

  42. Wilens TE. Drug therapy for adults with attention-deficit hyperactivity disorder. Drugs 2003;63(22):2395–411.[Medline]

  43. Wilens TE, Faraone SV, Biederman J. Attention-deficit/hyperactivity disorder in adults. JAMA 2004;292(5):619–23.[Free Full Text]

  44. Faraone SV, Biederman J, Roe C. Comparative efficacy of Adderall and methylphenidate in attention-deficit/hyperactivity disorder: a meta-analysis. J Clin Psychopharmacol 2002;22(5):468–73.[Medline]

  45. Spencer TJ. ADHD treatment across the life cycle. J Clin Psychiatry 2004;65(supplement 3):22–6.[Medline]

  46. Michelson D, Adler L, Spencer T, et al. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry 2003;53(2):112–20.[Medline]

  47. Himpel S, Banaschewski T, Heise CA, Rothenberger A. The safety of non-stimulant agents for the treatment of attention-deficit hyperactivity disorder. Expert Opin Drug Saf 2005;4(2):311–21.[Medline]

  48. Wilens TE, Biederman J, Mick E, Spencer TJ. A systematic assessment of tricyclic antidepressants in the treatment of adult attention-deficit hyperactivity disorder. J Nerv Ment Dis 1995;183(1):48–50.[Medline]

  49. Wilens TE, Biederman J, Prince J, et al. Six-week, double-blind, placebo-controlled study of desipramine for adult attention deficit hyperactivity disorder. Am J Psychiatry 1996:153(9):1147–53.[Abstract/Free Full Text]

  50. Daviss WB, Bentivoglio P, Racusin R, Brown KM, Bostic JQ, Wiley L. Bupropion sustained release in adolescents with comorbid attention-deficit/hyperactivity disorder and depression. J Am Acad Child Adolesc Psychiatry 2001;40(3):307–14.[Medline]

  51. Wilens TE, Prince JB, Spencer T, et al. An open trial of bupropion for the treatment of adults with attention-deficit/hyperactivity disorder and bipolar disorder. Biol Psychiatry 2003;54(1):9–16.[Medline]

  52. Wilens TE, Haight BR, Horrigan JP, et al. Bupropion XL in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled study. Biol Psychiatry 2005;57(7):793–801.[Medline]

  53. Safren SA, Sprich S, Chulvick S, Otto MW. Psychosocial treatments for adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am 2004;27(2):349–60.[Medline]

  54. Murphy K. Psychosocial treatments for ADHD in teens and adults: a practice-friendly review. J Clin Psychol 2005;61(5):607–19.[Medline]

  55. Kalbag AS, Levin FR. Adult ADHD and substance abuse: diagnostic and treatment issues. Subst Use Misuse 2005;40(13–14):1955–81, 2043–8.[Medline]

  56. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR, 4th ed, text revision. Washington: American Psychiatric Association; 2000:89.

  57. Barkley RA, Murphy KR, O’Connell T, Connor DF. Effects of two doses of methylphenidate on simulator driving performance in adults with attention deficit hyperactivity disorder. J Safety Res 2005;36(2):121–31.[Medline]

  58. Potter AS, Newhouse PA. Effects of acute nicotine administration on behavioral inhibition in adolescents with attention-deficit/hyperactivity disorder. Psychopharmacology (Berl) 2004;176(2):182–94.[Medline]

  59. Kollins SH, McClernon FJ, Fuemmeler BF. Association between smoking and attention-deficit/hyperactivity disorder symptoms in a population-based sample of young adults. Arch Gen Psychiatry 2005;62(10):1142–7.[Abstract/Free Full Text]

  60. Xu J, Mendrek A, Cohen MS, et al. Brain activity in cigarette smokers performing a working memory task: effect of smoking abstinence (published correction appears in Biol Psychiatry 2006;60[2]:204). Biol Psychiatry 2005;58(2):143–50.[Medline]

  61. Grossi SG, Genco RJ, Machtei EE, et al. Assessment of risk for periodontal disease, II: risk indicators for alveolar bone loss. J Periodontol 1995;66(1):23–9.[Medline]

  62. Montano B. Diagnosis and treatment of ADHD in adults in primary care. J Clin Psychiatry 2004;65(supplement 3):18–21.

  63. Smith AP. Caffeine at work. Hum Psychopharmacol 2005;20(6):441–5.[Medline]

  64. Bagheri R, Burrow MF, Tyas M. Influence of food-simulating solutions and surface finish on susceptibility to staining of aesthetic restorative materials. J Dent 2005;33(5):389–98.[Medline]

  65. Heller KE, Burt BA, Eklund SA. Sugared soda consumption and dental caries in the United States. J Dent Res 2001;80(10):1949–53.[Abstract/Free Full Text]

  66. Physicians’ desk reference 2006. 60th ed. Montvale, N.J.: Thomson PDR; 2006.

  67. McEvoy GK. AHFS Drug information 2006. Bethesda, Md.: American Society of Health-System Pharmacists; 2006.

  68. Spencer T, Biederman J, Wilens T, et al. A large, double-blind, randomized clinical trial of methylphenidate in the treatment of adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 2005;57(5):456–63.[Medline]

  69. Adler LA, Spencer TJ, Milton DR, Moore RJ, Michelson D. Long-term, open-label study of the safety and efficacy of atomoxetine in adults with attention-deficit/hyperactivity disorder: an interim analysis. J Clin Psychiatry 2005;66(3):294–9.[Medline]

  70. Gage TW, Pickett FA. Mosby’s dental drug reference. 6th ed. St. Louis: Mosby; 2003.

  71. Callahan AM, Marangell LB, Ketter TA. Evaluating the clinical significance of drug interactions: a systematic approach. Harv Rev Psychiatry 1996;4(3):153–8.[Medline]

  72. Haas DA. Adverse drug interactions in dental practice: interactions associated with analgesics—part III in a series. JADA 1999;130(3):397–407.[Abstract/Free Full Text]

  73. Ganzberg S. Psychoactive drugs. In: Ciancio SG, ed. ADA guide to dental therapeutics. 3rd ed. Chicago: American Dental Association; 2003:382–411.

  74. Yagiela JA. Adverse drug interactions in dental practice: interactions associated with vasoconstrictors—part V of a series. JADA 1999;130(5):701–9.[Abstract/Free Full Text]

  75. Broquet KE. Status of treatment of depression. South Med J 1999;92(9):846–56.[Medline]





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