DENTAL CARE FORPERSONS WITH MENTAL ILLNESS

PRESENTER- TEJASWITA SINGH

GOOD MORNING

What Dental Professionals Should Know about Psychiatric Disorders —

• They are prevalent.

• They are under-recognized and under-diagnosed.

• They are frequently misunderstood.

• They are associated with high rates of medical co-morbidity and increased dental problems.

• They are associated with reduced rates of compliance with dental and medical treatments.

• Psychiatric illness may present with physical symptoms (e.g., pain).

• Psychiatric disorders are associated with higher rates of substance use disorders.

• Psychotropic medications may have short- and long-term adverse effects.

• Psychotropic medications may interact with drugs used in dentistry and with other medications

patients are taking.

Adapted from: Stephen Ferrando, M.D., Northwestern University

Introduction

Dentists are trained to provide treatment for patients with straightforward problems that respond to routine therapy and do not recur.

Patients may present to dentists and complain solely of resistant chronic or recurrent physical symptoms such as toothache, headache, and facial pain.

After investigations & treatments these physical symptoms are revealed to be due to emotional disturbance.

Anxiety in dental setting may manifest itself as a phobia or a dysmorphic concern about certain aspects of patients’ appearance.

Psychiatric conditions affecting dental health

Classification of mental disorders:-

Chronic idiopathic facial pain (Somatic symptom and related disorders)

Body dysmorphic disorder

Anorexia nervosa and bulimia.

Dental phobia.

Mood disorders (depression, mania)

Psychotic disorders

Substance use disorders

Dementia

Intellectual developmental disability

Psychotropic drugs

Chronic idiopathic facial pain

Prevalence is generally 15%. The mean age for facial arthromyalgia is 30. The mean age for atypical facial pain is 55 years old. Females > males 4 :1

Clinical features of Chronic idiopathic facial pain Symptom complexes

Clinical features

Facial Arthromyalgia (FAM)

Uni- or bilateral pain in the temporomandibular joint (TMJ) and associated craniofacial musculature, and there may also be a sense of fullness, popping, or tinnitus in the ear

Atypical facial pain (AFP) (or idiopathic facial pain)

A continuous ache with intermittent excruciating episodes, localized to the non muscular, non joint areas of the face. The pain may be uni- or bilateral and may persist for months or years.

CONTD…

Symptom complexes

Clinical features

Atypical odontalgia (AO)

The dental variant, which is diagnosed in theabsence of detectable dental pathology.

Oral dysesthesia Includes: a burning discomfort in the tongue (glossopyrosis), gingiva, or lips a persistently dry mouth in the presence of salivaa disturbance of taste denture intolerancea persistently uncomfortable occlusion (phantom bite or occlusal hyperawareness).

ETIOLOGY of Chronic idiopathic facial pain Idiopathic. The psychosocial features include: an unstable or inadequate parental

background poor adaptation to school or workmarital and financial difficultieschronic illness in the familybereavement fewer sources of emotional support

TREATMENT Counselling about lifestyle and support in any emotional crisis. Those with complex emotional history, depression, or agitated or psychotic

states should be treated by a liaison psychiatrist or a psychologist. Joint clinic is needed to avoid the perceived stigma of a psychiatric diagnosis.

Medications : Tricyclic antidepressant e.g nortriptyline. *S/E: Drowsiness and xerostomia, weight gain and constipation. SSRIs e.g. Fluoxetine. Cognitive therapy ± drugs. Hypnosis.

BODY DYSMORPHIC DISORDER (BDD)

BDD is the belief in a cosmetic defect in a person of normal appearance.

The complaint may range from mild unattractiveness to ugliness.

Face and its components (the teeth, nose, mouth, ears, eyes, and chin) make up a large percentage of structures for which patients seek and undergo cosmetic surgery.

These patients often have bizarre complaints about their profile or their smile.

The disorder is in fact not a phobia at all but rather an obsession, or a delusion.

Treatment of BDD

The problem is whether to do what the patient wants, what the patient needs, or nothing.

The outcome of surgery or repeated surgeries are usually unsatisfactory, except where some recognizable deformity has been carefully corrected, patient's expectations are realistic and the patient appears able to withstand an imperfect result.

The relationship between the surgeon and patient is a vital factor in achieving good results and a psychiatrist should be included in clinical management.

BDD patients may respond well to Fluoxetine, both alone and in combination with cognitive therapy.

Anorexia nervosa and bulimia

Anorexia nervosa is a pathological avoidance of food in which the subject has a delusional body image.

Despite emaciation, they see themselves as being fat and, apart from limiting their food intake, there is often a covert practice of vomiting.

The bulimic nervosa subject : by self-induced vomiting, maintains a normal weight despite indulging in eating binges.

Both conditions eventually lead to erosion of the teeth and caries due to the constantly regurgitated gastric juice.

Treatment requires the cooperation of the patient, a restorative dentist, and a psychiatrist.

Dental phobia

Dental phobia

It is normal for individuals to feel some anxiety about dental treatment.

Prevalence: 8-13%, F>M, onset ≤20 years old, chronic course Todd and Walker (1980) interviewed 6000 British citizens and

found that 43% of them avoided going to the dentist unless they were in trouble.

Kent (1984) , in a survey of the worst stresses encountered by dentists: coping with difficult, anxious patients.

The situation is complicated, anxious patients expect treatment to be painful, and their anxiety is not modified by a painless experience.

Coping with anxiety means that patients' preconceptions about treatment must be modified .

Dental phobia (vicious cycle)

Risk factors of Dental phobia

Anticipating pain Uncertainty about particular treatments Bad previous experience Females Lower school education Lower social classes Dentist's behaviour Biological propensity to develop anxiety.

Prevention of Dental phobia

Public dental health education

Dental Care need to be :

long-term frequent regular by one dentist including sessions devoted purely to educational

aims, perhaps conducted in small groups.

Management of Dental phobia

Reassurance. Adequate pre-treatment analgesia or a mild tranquilizer

such as diazepam? Addiction. Use of distraction such as listening to relaxation tapes. Giving the patient some control over their treatments such

as raising an arm to stop drilling. Cognitive behavioural therapy. Referral to a psychiatrist.

Mood Disorders

Unipolar Depression- Episode lasts 6-9 m 0r more Bipolar Mood Disorder- Episode lasts about 6m Dysthymia- About 2 years Cyclothymia- Rapid changes in mood Due to the long term course of the illnesses, patient lacks

motivation to take care of personal hygiene. Though the patient doesn’t loose insight but due to

psychomotor retardation he is unable to take care of his routine hygiene.

Psychotic disorders

Schizophrenia and related Psychotic disorders Delusional disorders Acute and transient psychotic disorders Thought disorder where generally the patient’s insight is

absent where he’s unable to recognize what he’s suffering from and how.

Often symptoms of bizarre eating behavior from ground/uneatable things used to be present for months together.

Substance use disorders

Tobacco (Cigarette, Gutka, Tambaku Paste) Alcohol Stimulants like (Caffeine, Methamphetamine) Opioids (Codeine syp) Dendrite (Huffing) All these substances are used orally and pose risk of

developing oral and dental health problems.

Dementia

Person developing immediate, recent and remote memory loss along with other cognitive disturbances becomes unable to take care even of his routine day today life.

Hence personal oral and dental hygiene do suffer along with the advancing age which itself poses a big risk.

Intellectual Developmental Disability

Mild to Profound IDD patients always depend on care takers for routine day today activities.

Personal hygiene is always an issue with these special groups of patients.

Mild to Moderate IDD are trainable whereas Severe to Profound IDD always require some form of help in routine works.

Psychotropic drugs

Antidepressants Antipsychotics Sedatives, hypnotics Mood stabilizers Most of the drugs from above groups cause dry mouth as a

common symptom due to their anticholinergic side effects. Some of the drugs can cause hypotension, cardiac

arrhythmias so vasoconstrictors use should be cautioned.

Dental problems in psychiatric illness Dry mouth Apthous ulcers Xerostomia Dental caries Periodontal disease Tooth wear Submucous fibrosis Oral cancer

VARIOUS RESEARCHES…

CONTD…

CONTD…

Preventive Measures

The basic messages for oral health promotion and disease prevention should include the following: Brushing twice a day with a fluoridated toothpaste. Avoidance of sugars in foods or carbonated drinks. Healthy eating habits. Smoking cessation and keeping alcohol

consumption to a minimum. Saliva substitutes can help with dry mouth

secondary to psychotropic medication. Regular dental check-ups and be prepared to

address dental anxiety and phobia, if present.

SND- WHAT????

SPECIAL NEEDS DENTISTRY

DEFINITION:“That part of dentistry concerned with oral health of people adversely affected by intellectual disability, medical, physical or psychiatric issues.” (RACDS)

New Zealand, Australia- 2003

United Kingdom (SCD)- 2008

Malaysia- 2008

http://www.racds.org/

Take Home Message

As we came to know that a dental problem can cause a psychiatric issue and vice versa, a proper history before assessment is utmost important.

30% of dental visits are having some emotional issues.

Fear and anxiety can be reduced by proper explaining of the disease process and management procedures.

Timely follow-ups Integrated approach Special Needs require Special Care

THANK

YOU