Dental-Mental Inter relationship

1. DENTAL CARE FOR
PERSONS WITH
MENTAL ILLNESS
PRESENTER- TEJASWITA SINGH

2. GOOD MORNING

3. 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

4. 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.

5. 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

6. 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

7. Clinical features of Chronic idiopathic facial
pain
Symptom
complexes
Clinical features
Facial
Arthromya
lgia (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.

8. CONTD…
Symptom
complexes
Clinical features
Atypical
odontalgia (AO)
The dental variant, which is diagnosed in the
absence 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 saliva
a disturbance of taste
denture intolerance
a persistently uncomfortable occlusion (phantom
bite or occlusal hyperawareness).

9. ETIOLOGY of Chronic idiopathic facial pain
 Idiopathic.
 The psychosocial features include:
 an unstable or inadequate parental background
 poor adaptation to school or work
 marital and financial difficulties
 chronic illness in the family
 bereavement
 fewer sources of emotional support

10. 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.

11. 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.

12. 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.

14. 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.

15. Dental phobia

16. 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 .

17. Dental phobia (vicious cycle)

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

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

28. VARIOUS RESEARCHES…

29. CONTD…

30. CONTD…

31. 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.

32. SND- WHAT????

33. 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/

34. 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

35. T
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