Your Patients are on Drugs
One in every 6 white fifth-grade boys in Virginia Beach, Va was taking Ritalin in 1996, according to a recent editorial in a Richmond newspaper. If you think that this is a local curiosity, think again. The same editorial reports that prescriptions for Ritalin have risen 700% in the past decade and that American children consume 5 times as much Ritalin as the rest of the world combined. You are almost surely seeing patients on Ritalin every day in your practice.
Ritalin usage is a controversial subject. The proponents of the drug give testimonials describing how the drug helps children to focus and to concentrate. The opponents say adults are simply using the drug to control the exuberance of youth. More recently, the drug has been in the news again, with a growing use in preschool children despite the unknown consequences of the drug on the still-developing nervous system.
Why do children and adolescents take Ritalin? More than 3 million American children have been diagnosed with Attention Deficit Disorder (ADD) and are being treated with Ritalin. The diagnosis is largely behavioral. A 1990 report in the New England Journal of Medicine noted differences in glucose metabolism between hyperactive adults and controls. Mary Eberstadt notes in “Why Ritalin Rules” (Policy Review, April–May 1999) that a series of other studies were unable to confirm these findings. She further cites from a standard reference book for recognized psychiatric disorders that the criteria for the diagnosis of ADD in children include 14 activities such as fidgeting, squirming, distraction by extraneous stimuli, difficulty waiting turns, blurting out answers, losing things, interrupting, and ignoring adults. Thomas Armstrong's book The Myth of the ADD Child says the diagnosis still depends almost exclusively on behavioral criteria. Our local newspaper editorial cites the parallel between the use of Ritalin and the days when parents quieted their children with laudanum, an opiate in alcohol.
How does Ritalin work? Some believe that the drug is a sedative. It is not. Eberstadt noted that a 1995 Drug Enforcement Administration background paper says Ritalin “is a CNS stimulant and shares many of the pharmacological effects of amphetamine, methamphetamine and cocaine.” My local pharmacologist explained to me that the Controlled Substance Classification of Ritalin is Schedule II, the same as for cocaine and amphetamines. Drugs are placed in Schedule II on the basis of their potential for abuse and the ability of the abuse to lead to psychic or physical dependence. Schedules go from I to VI, with the greatest addiction potential in Schedule I. Why aren't Ritalin, cocaine or amphetamines in Schedule I? That is because a Schedule I drug is illegal to own and is used for research purposes only.
We can expect our patients on Ritalin to be attentive when under the influence of the drug and to rebound when the effects of the drug wear off. We can expect them to report loss of appetite and insomnia, just as other stimulants affect all patients. I met my first hyperactive patient with an attention span problem more than 20 years ago. He (more ADD patients are male) was the son of a medical doctor, and the father told me that it was a peculiar thing because, even though the drug was a stimulant, it acted on these hyperactive patients as a depressant. A pharmacologist recently told me of a dentist who thought that his son was so much better able to concentrate when on Ritalin that the whole family is on the drug now. Clearly, the dentist believes in it with evangelical fervor.
Does Ritalin affect an orthodontic practice? All of us have seen hypertrophied gingival responses—some drug complicated—during orthodontic treatment. The mechanism of these gingival responses remains incompletely understood. Does Ritalin affect the gingival tissue? We do not know the answer.
This question transcends our concern of whether Ritalin will potentiate gingival enlargement during orthodontic care. More importantly, we are treating millions of our children with a powerful central nervous system stimulant for an ill-defined behavioral problem. DeGrandpre, in his book, Ritalin Nation, cites a 1995 paper in Archives of General Psychiatry that says, “Cocaine, which is one of the most reinforcing and addicting of the abused drugs, has pharmacological actions that are very similar to those of methylphenidate (the chemical name for Ritalin), which is now the most commonly prescribed psychotropic medicine for children in the U.S.”
When you see a patient's health history that cites Ritalin, and you surely will see many of them, consider what we do not know about this patient. The response of the gingival tissue is only a small part of the question. What behavioral modifications should you expect? Does the Ritalin-treated patient cooperate better? On the other hand, is Ritalin use a signal for us to modify our normal treatment plans? We just do not know very much about the impact of this enigmatic drug on orthodontic care. Worst of all, we do not know enough about how this drug acts on the lives of millions of our children. Passing through adolescence is a difficult period and may require lots of help. Is the pervasive use of drugs the best help for this problem?