Dental considerations of psychiatric disorders

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Information about Dental considerations of psychiatric disorders

Published on March 12, 2014

Author: magician10k



 Mental illnesses are medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others, and daily functioning.  Not related to a person’s character— brain based disorder!

Disorders of mood, thinking, and behavior may be due to:- Primary: Psychiatric diagnosis (Axis I diagnosis) or personality disorders (Axis II diagnosis) Secondary: Metabolic abnormalities, drug toxicities, focal cerebral lesions, seizure disorders, or degenerative neurologic disease.

 Medications used to treat mental illness can interact with drugs used in dentistry.  Some oral health problems arise as manifestations of mental illness.  Oral health problems as side effects of psychotropic medications.  Decreased compliance to oral health care/ability to obtain or tolerate oral care treatment.

1. Exaggeration, distortion of normal function, e.g. delusions, hallucinations. 2. A rapid shift of ideas, incoherent speech, poor thought relation. Disorganized, bizarre behavior 3. Flat emotions/emotional expression, lack of motivation, monotony of speech, apathy, social withdrawal, absence of normal drives or interests such as those involving one’s self care (general/oral).

…people who suffer from schizophrenia are at a far greater risk of dental caries, gingivitis/advanced periodontal disease, tooth loss, poor oral hygiene, mucosal diseases… + poor dietary habits, smoking, alcohol abuse, substance abuse…  higher prevalence of bruxism and signs of TMD = severe tooth damage due to extensive attrition.  actual pain sensitivity thresholds higher in patients cause delays in diagnosis and treatment resulting in serious clinical consequences.

ORAL DYSKINESIAS Abnormal involuntary, uncontrollable movements affecting primarily the tongue, lips, jaws (can extend to trunk/limbs) Causes: 1. drug induced (conventional antipsychotics)** 2. neuropsychiatric conditions 3. edentulousness (**tardive dyskinesia)

ORAL DYSKINESIAS- Complications  tooth wear  oral pain/injury  TMJ degeneration  speech impairment  chewing difficulties  inadequate food intake…wt. loss  displacement/poor retention of removable partial dentures (RPD’s)…decreased tolerance  social sequelae

 Conventional Antipsychotics: chlorpromazine, haloperidol Oral side effects: xerostomia, dyskinesia  Atypical Antipsychotics: clozapine,risperidone Oral side effects: xerostomia, dysphagia, stomatitis

 acidic plaque pH…caries, hypersensitivity  loss of lubrication…oral ulcerations, difficulties eating, speaking, wearing dentures  dec. amount of saliva…inc. infections (viral, bacterial, fungal) digestion problems, ease of trauma to oral mucosa, gingivitis & periodontitis

 Epinephrine used with caution to prevent severe hypertensive episode – limit to 2 carpules 1:100,000; avoid epinephrine in retraction cords; inject slowly.  Neuroleptics may intensify effects of sedatives, hypnotics, opioids, antihistamines – leading to severe respiratory depression – consult with MD.  Neuroleptics can dec. blood levels of warfarin.

fluoride supplements (e.g.Prevident) oral hygiene salivary substitutes (re: dry mouth) Clozapine use & agranulocytosis freq. recall appts. empathy, support, MD consultation meds/consent/psych. status

 second leading cause of death and disability in the world in age category of 15-44 yrs. (M & F) – W.H.O.  an illness affecting the entire body  leading cause of alcohol/drug abuse (1/3 of patients) Depression will be…..  The second leading cause of health impairment worldwide by 2020. (WHO)

 Feeling: sad, helpless, hopeless, irritable, angry, agitated, anxious, or any combination of the preceding  A loss of interest or pleasure in previously enjoyed activities  A sense of worthlessness or guilt accompanied by preoccupation over past minor failings  Complaints of bodily aches and pains without a physiological basis  Social withdrawal  Increasing prevalence among the elderly, is the most common emotional disorder in people older than 65 years

 Prone to suffer periodontitis due to: neglect of oral hygiene  Increased smoking  Altered immune  Clenching, grinding of the teeth (bruxism)  Rampant dental decay due to: disinterest in performing oral hygiene practice  Preference for carbohydrates resulting from reduced serotonin levels  Craving for intense sweets because of impaired taste perception  Decrease in salivary output  A high lactobacillus count  Chronic facial pain  Burning sensation of the tongue  Bad Breath  Oral yeast infections  TMJ-temporomandibular joint disorder is frequently the complaint that brings the depressed person to the dentist.

 xerostomia-dry mouth  altered taste sensations  infections in the mouth  infection in the tongue  infection in the gums  discoloration of the tongue  severe gum disease-periodontitis  clenching, grinding of the teeth- bruxism

 Mood stabilizers: Lithium Oral side effects: xerostomia, lichenoid stomatitis, metallic taste  Tricyclic antidepressants: Oral side effects: xerostomia, possible potentiation of pressor effects in epinephrine in local anesthetics; use of levonordefrin contraindicated; use of retraction cord with epinephrine contraindicated.  Selective serotonin reuptake inhibitors(SSRIs): Oral side effects: xerostomia, stomatitis, glossitis, bruxism

 increased presence of TMD signs (14% of patients with signs of TMD also have comorbid psych. symptoms c/w depression i.e. wt. loss, sleep disturbances, energy loss, changes in concentration)  increased dental attrition/incidence of bruxism

 Medical/Dental history Obtain current medication regimen including history of alcohol or other substance abuse  Dental education on preventive dental education is paramount to receive instruction in proper toothbrushing and flossing methods that maximize removal of dental plaque  Increased water intake.  Regularly scheduled dental visits.  Precautions related to low blood pressure-hypotension : decreased length of dental visits, positioning somewhat upright in the dental chair, blood pressure monitoring, using caution in prescribing medications with additional orthostatic hypotension.  Use of saliva substitutes  Anticaries agents containing fluoride  Dental treatments that may consist of subgingival scaling, root planing and curettage, caries control and restorative treatment  Special precautions when prescribing or administering analgesics and local analgesics  Awareness of potential adverse interactions of antidepressants with other medications

Anorexia Nervosa Bulimia Nervosa  living in fear of food; of being fat  diagnosis has reached epidemic proportions

―ceaseless pursuit of thinness‖  1% of females aged 12 – 25 yrs.  mostly white/middle class background.  extreme distortion/percepti on of body image.

Binge eating twice weekly over a 3 month period of time followed by self-induced vomiting, laxatives, diuretics, enemas, excessive exercise regimens. (may in fact be of a more normal weight)

 Anorexia Nervosa: arise as a result of starvation (restricting) and weight loss.  Bulimia Nervosa: related to the mode and frequency of purging.

Finding Anorexia Nervosa Bulimia Nervosa Lingual erosion no yes Tooth sensitivity no yes Xerostomia yes yes Dental caries no yes Perio. disease no yes Enlarged parotid** yes yes Mucosal atrophy yes no Poor oral hygiene no yes

Lingual surface erosive pattern:  Bulimia (perimyolysis), chronic gastritis secondary to chronic alcoholism, GERD. (+/- affecting the occlusal surfaces of premolars/molars, further exacerbated by attrition.)

1. Reduce frequency of acid exposure on teeth.  achieving a reduction in the no. of episodes of vomiting to complete cessation. 2. Enhance salivary flow.  sugar free mints, chewing gum to stimulate salivary flow  water for oral lubrication

3. Neutralize acids in the mouth.  use of alkaline mouth rinse immediately after vomiting(NaHCO3), water, milk 4. Increase resistance of enamel to demineralization.  daily fluoride rinse 0.5%  fluoride gels (1.1%) in custom trays

5. Minimize abrasive brushing techniques  soft brush, circular motion  avoid brushing immediately after episodes of vomiting 6. Caries prevention  NaF varnishes  sealants  snack substitutes  desensitizing agents

Anorexia Nervosa: ◦ regain lost weight ◦ stabilize physical health Bulimia Nervosa: ◦ end cycle of binge eating/ vomiting ◦ temporary coronal coverage followed by eventual RCT/ cast restorations as required (Relapse is common if vomiting recurs)

Anxiety – what is it? ―emotional pain or a feeling that all is not well-a feeling of impending disaster‖ The physiological reaction/response occurs via ANS- can include inc. heart rate, sweating, dilated pupils, inc. urge of urination, diarrhea.

Mild form of anxiety towards dental care – Treatment Strategies 1. General attitude/anxiety reducing treatment style  providing trust  providing control  providing realistic information  apply high level of predictability 2. Pharmacological support  pre-medication  nitrous oxide sedation 3. Teaching of coping strategies  distraction  relaxation  hypnosis

 Pre-op: - explain, honesty, answer questions, consistent communication. **oral sedation (benzodiazepines)  Operative: - answer questions, reassurance. **L.A. oral/IM/IV sedation, N2O2  Post-op: - explain what to expect, what to do/not do, possible complications( i.e. pain, bleeding, infections), who to contact. **analgesics, +/- antibiotics

Some patients who undergo psychiatric care for e.g. depression may be reluctant to admit this fact due to the stigma attached to the psychiatric diagnosis. Dentistry must overcome such barriers:  obtain all relevant information  supportive, non-judgmental attitude  ensuring confidentiality  emphasizing the need to be provided safe dental care.

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