PSYCHIATRIC DISORDERS IN DENTISTRY.pptx

BY DR.FAMUREWA B.A. O.A.U.T.H.C., ILE-IFE, NIGERIA.

INTRODUCTION PSYCHIATRIC DISORDERS AND ORAL HEALTH PSYCHOGENIC ORAL DISEASES PSYCHIATRIC MEDICATIONS AND ORAL HEALTH DRUG INTERACTION CONCLUSIONB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Royal Bethlehem Hospital Bedlamc18th

B.A. FAMUREWA, B.ChD

Tuesday, August 14, 2012

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Introduction Persons with co-morbid mental and oral disorders are part of patients presenting to various dental health facilities. This presents challenges to dental personnel in terms of diagnosis and treatment .

Hence, this presentation seeks to elucidate the relevant nexus between mental and oral health



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Introduction The 3 dimensions that unite oral and mental health: PSYCHIATRIC DISORDERS AND ORAL HEALTH

PSYCHOGENIC ORAL DISEASES PSYCHIATRIC MEDICATIONS AND ORAL HEALTHB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Dental

anxiety

Psychosis Mood

disorders

Substance abuse



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Dental Anxiety has been defined as a state of unpleasant feelings combined with an associated feeling of impending doom or danger from within rather than from without. On the other hand, dental fear is a response to a real or active threat which is usually brief.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Some clinical features of dental anxiety include: 1. Excessive worry over oral health and its treatment procedure 2.Recurrent unexplained symptoms of oral pathology such as oro-facial pain, headache 3. Excessive sweating most especially on the palm 4. Trembling 5.Shortness of breath 6.Somatic symptoms (such as crawling sensation, internal heat etc) 7. Palpitation.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Types:

1. Mild 2. Morderate 3. Severe( Dental phobia)



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Epidemiology In

a recent study in Nigeria by Coker et al (2008), 29% of attendees in a dental Clinic had dental anxiety and this figure is lower than most of those obtained from studies in the western world such as Wake (1999); Moore (2004) and Kloosa et al (2007). The global estimate for dental anxiety has been put at 615% (Eli et al, 2004).



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Epidemiology Dental anxiety is commoner in younger children

When compared with prevalence figure of 29% for Nigerian adults attending dental clinic, figures in children are comparatively slightly higher.For instance, Sote and Sote (1985) found 29.8% while Folayan (2000) obtained 33.7% for dental anxiety among children attendees of hospital based dental clinics in Nigeria.



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MANAGEMENT

Preventive

1. Dental health education 2.Procedures should be honestly explained Definitive 1. Psychological/behavioural 2.Pharmacological



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Psychological

management Minimize dental anxiety triggers; that is the 4S rule which aims to reduce the triggers of stress, such as: Sight Sound Sensation Smell



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1.The 4S rule: Sights (of Needles, drills): placing instruments where they are blocked from view or covered. Sounds (drilling): reduce the offensive sound to

the barest minimum

Sensations (high frequency vibrations) :should be

minimized as much as possible.

Smells (Clinical odours, such as eugenol and

bonding agents): spray a scented oil fragrance to reduce the clinical aroma of the treatment room.



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2.Relaxation therapies -Jacobsens muscular relaxation -Overbreathing exercise 3.Distraction techniques 4.Systematic desensitization 5.Cognitive behavioural therapy



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Pharmacological

approach

1.Anxiolytic agents; premedication and/or parenteral .Examples Diazepam, midazolam 2.Anaesthetic agents- Nitrous oxide, Oxygen 3. Antidepressants(in chronic cases)



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Psychosis

is a form of mental illness characterized by hallucination, delusion and personality disorder. It includes the following: 1.Schizophrenia 2.Schizophreniform 3.Schizoaffective

disorder

disorder

4.Delusional

disorder



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Epidemiology In a study conducted by Janardhanan & colleague (2011) in US, 41 of the studied population with schizophrenia reported having problems with their teeth or dentures. Akpata et al ( 2006) reported increasing prevalence of delusional halitosis in a university community.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Dental

presentations

Aliens are controlling me through transmitters

implanted under my fillings............I want them out.

Mouth infestation by worms or insects Delusions of pain

Delusion of oral malodour Trauma to gingivae( recession) and teeth( cervical

abrasion) 2 to overzealous brushingB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Could

be

Unipolar disorder( Depression) Bipolar disorder- characterized by variation in

individuals mood, thought content and behavioural pattern between extreme elation (mania) and depression



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Ten key symptoms of depression: Depressed mood (for>2weeks) Loss of interest and pleasure (anhedonia) Loss of confidence and self-esteem Self-reproach or guilt Recurrent thoughts of suicide or death Diminished concentration or indecisiveness Fatigue and loss of energy Agitation and psychomotor retardation Sleep disturbance (e.g early morning waking) Appetite and weight change (usually lost)



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Manic symptoms: 1.Execessive high or euphoric feelings 2.Obnoxious, provocative or intrusive behaviour 3.Unrealistic beliefs in ones abilities 4.Difficulty concentrating, remembering and making decisions. 5. Denial that anything is wrongB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Dental presentations Depression: 1. Neglect of oral hygiene2.

Existing prosthesis may be discarded or ill-fitting.



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Dental presentation Mania 1. Overzealous tooth-brushing and flossing 2. Demand for expensive cosmetic dental treatment



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Substance use is the consumption of low or infrequent doses of alcohol or drugs such that damaging consequences are rare or minor. Substance abuse is a disorder characterized by repetitive drug use that results in social or economic distress with related medical problems.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Epidemiology Globally, 200 million people abuse drugs(2007). Studies from Nigeria showed prevalence rate of 2-9% among secondary school students; and the rates are much higher among university undergraduates.

In a Nigerian university survey, 33% of the male students and 2.2% of females admitted smoking cannabis. It is also the most incriminated substance in a survey of drug-related admissions for in-patient management in 28 psychiatric facilities in Nigeria.



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Commonly abused drugs: Narcotics- Opium, Morphine, Codeine, Heroin Cannabis-

Marijuana, Hashish

Stimulants-

Methamphetamine, Cocaine Amphetamine



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Commonly abused drugs contd: Hallucinogens- Lysergic acid diethylamide(LSD), Mescaline, Psilocybin Depressants-

Alcohol, benzodiazepines,

barbiturates Miscellaneous:

Antihistaminics, Solvents in aerosols, Anabolic steroids.



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Oral lesions in Cannabis: Gingival enlargement Cannabis

stomatitis( dry mouth, numbness of oral cavity) Leukoplakia Oral

malignancies



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Oral lesions in Cocaine: Cervical abrasion, gingival laceration and/or recession 2 to overzealous brushing when high. Bruxism TMJ

disorders

Glossitis

and leukoedema 2 to chewing of coca leaves and slaked lime



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Oral lesions in Methamphetamines: Meth mouth- the term used to describe effects of methamphetamine on oral hard and soft tissues. Dental caries( smooth surface) Xerostomia Gingivitis Periodontitis Bruxism



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Oral lesions in Alcohol: Attrition 2 to bruxism during sleeping Xerostomia( Dental

Parotid enlargement)

caries diseases

Periodontal Oral

malignancy



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These

are oral disorders initiated or aggravated by existing emotional disturbance. disturbance:

Emotional

Stress Depression Anxiety



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Stress Term used in different ways: To indicate presence of stressors

To describe experience of being stressed To describe an emotional disorder associated with stress Used in a negative sense BUT can be positive What is stressful to one person may not be to another coping skills



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Some

physical diseases are believed to have a mental component derived from the stresses and strains of everyday living Anxiety and stressful life events can give rise to oro-facial symptomsB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Diagnosis of psychosomatic symptomdoes not necessarily imply that the patient has an underlying psychiatric illnessB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Irritable bowel syndrome Hypertension Low back pain Chronic fatigue syndrome

Psychogenic oral diseases: TMPDS Oral dysaesthesia Disruptive gagging Dry mouth Anorexia nervosa Atypical facial pain Tension headache Panic attacksTuesday, August 14, 2012


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The

dentists must always eliminate any organic cause for patients symptoms before diagnosing them as psychosomatic disorder. queries during history taking.

Helpful



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How Has

are you sleeping? your appetite been affected by this condition? the complaint stop you from enjoying yourself

Does How

does your family/friend react to your condition?any thing take your mind off it?

Do you have any idea what caused the pain?

Does



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These are: Chronic orofacial pain( Psychogenic pain) Atypical facial pain Atypical odontalgia Oral dysaethesia Burning mouth syndrome Temporomandibular pain dysfunction syndrome

(TMPDS).



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Delusional

symptoms:

Delusional/Psychogenic halitosis Phantom bite syndrome Lump or seeds under the mucosa



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Body dysmorphic disorder( BDD) injurious behaviour disorders

Self

Eating

Anorexia nervosa Bulimia nervosa



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Psychogenic Chronic Oro-Fcaial Pain

Atypical Facial Pain

Atypical Odontalgia

Burning Mouth Syndrome

Atypical odontalgiaB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Pain

is the commonest symptom seen in dentistry. Pain in the face and mouth may be of a local pathology, may be referred or may have no organic basis (psychogenic). About 50% of psychogenic pain are based in the head and neck.



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Pain

due to muscle tension (anxiety, depression, hypochondriasis). Anxiety muscular tension metabolites pain metabolites pain Conversion hysteria-repression of emotional conflict and conversion to somatic symptoms. Pain may be an hallucination or psychotic disorder (endogenous depression, schizophrenia).



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Pain

distribution not consistent with anatomical distribution. Pain may cross the midline or may occur bilaterally. Pain is usually continuous over a long period of time with no remission or change in xter. Pain may prevent patient from sleeping but it does no wake patient from sleep.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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There

may be a long history of various investigation with no organic pathology. Previous treatments including use of analgesics may have produced transient or no appreciable relief. Pt may describe the pain as being clearly associated with emotional factors and description may produce emotional outpouring.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Middle-aged Continuous Not

women

dull ache

provoked by movement or touch

Aggravated Does

by fatigue, worry or emotional stresssites

not respond to analgesics

Non-muscular

Lasts

for hours or dayshistory of surgery or dental treatmentB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

Recent

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Occur

more frequently in elderly females Presents as dull, poorly localized vague dull ache in the soft tissue or bone. Distribution of pain is not anatomical. May complain of other associated pain e.g back pain, body ache. Associated symptoms may include fatigue, sleep disorders, tension, irritability and lethargy.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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80%

have other chronic pain conditions

Irritable bowel syndrome Dysmenorrhoea Tension headache Fibromyalgia Chronic fatigue syndrome

Considerable

overlap with TMPDSB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Detailed

history (of emotional disturbance) and careful assessment to R/O organic causes. patient.

Reassure

Medications Anxiolytics- Lexotan, diazepam.

Antidepressants-TCA, MAOI. Psychiatric

consultation(if necessary).B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Teeth

appear clinically &

radiographically sound Pain

may persist after to another tooth

extraction OR Moved



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Specifically

of oral mucosa Comprises glossodynia (painful tongue), glossopyrosis (burning tongue). May be accompanied by metallic taste or dry mouth). There may be evidence of neurotic depression and anxiety disorder.



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Two forms: A. With observable clinical signs and symptoms Undiagnosed DM, Vitamin B complex deficiency Pernicious anaemia, Iron deficiency anaemia, Prosthetic/orthodontic appliance, Medicaments, dentrifices, Rarely allergy to cosmetics, Malignancy of the tongue, Lichen planus, Trauma, CandidiasisB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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B.Without observable clinical signs and symptoms. Forms the larger group Occurs in women in 4th 7th decade of life. Pain without observable signs and symptoms Pain is usually psychogenicB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Detailed history Thorough clinical examinations Investigations to R/O organic diseases Fe def anaemia, pernicious anaemia, candidiasis., geographic tongue. Full blood count Random blood sugar( FBS, 2hr-PP) Urinalysis

Reassure Sedatives AnxiolyticsB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Definition:

Burning sensation in the oral cavity with apparent clinically normal mucosa

Gender

distribution: M:F = 1:7 Age peak: 50 yrs. Sites most commonly affected: Tongue Palate LipsB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Type 1: Symptom-free waking, with sensation develops in the morning and progressively increasing to severe by evening Type 2: Continuous symptoms throughout the day Type 3: Intermittent symptom-free periods throughout the dayDay hoursB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Systemic factors

Psychogenic factors

Local factors



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Systemic

Vit. B1, B2, B6, B12

Local

Fe Folic acid Diabetes mellitus

Candidal growth Denture design Para-functional habits Xerostomia

Menopause Psychological

Allergy (? Restorative or

Cancer phobia Anxiety Depression

denture material) Gastro-oesophygeal reflux disease



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Detailed

clinical history Full clinical examination Blood tests Full heamatological investigation (CBC, Serum B12, Serum

& red cell folate, Serum ferritin) Zinc FBG Microbiological

investigations (for Candida species) Assessment of salivary gland function (salivary flow rate)



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Identify and correct the etiological factor



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Pain

(burning) control

Topical anaesthetics Antidepressants

Tricyclic antidepressants: cardiac patients need

consultation Anxiolytics

Benzodiazepines: may cause dependence Reassurance

& cognitive behavioral therapy



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Spontaneous remission is expected in few patients



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Positively

linked to stress and anxiety. Commoner in females Symptomatology of TMPDS: Pre-auricular pain(may radiate to other sites) Tendernsess of the joint Limited jaw opening Jaw deviation on opening and closing

Joint sounds( clicks +/- crepitus)



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Management Good history and clinical examination Relevant investigations Counselling Drugs Physiotherapy Soft diet ReviewB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Is

an abnormal belief, the patient deals with it as a fact

Examples: Delusional halitosis Phantom bite syndrome Lumps or seeds under the mucosa Management: Organic causes should be eliminated Psychological assessment & referralB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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This is a disorder whereby a patient complains of mouth odour that cannot be clinically substantiated or perceived by others. The patient insists in the presence of this odour despite argument to the contrary from significant others and the dental practitioners. In some of such patients, halitosis could be a manifestation of underlying uncinate fit or bizarre delusion seen in schizophrenic or severly depressed patients.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Body

dysmorphic disorder (BDD) is an obsessive preoccupation with a perceived defect in one's physical appearance. The individual persistently seeks medical attention to correct surgically. BDD often goes unrecognized and undiagnosed, due to patients' reluctance to divulge their symptoms because of secrecy and shame.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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This

preoccupation causes clinically important distress or impairs work, social or personal functioning Encourages gratuitous seeking of help from various physicians thereby causing much time wasting and high expenses. The individual is never satisfied with the outcome of any corrective surgery done.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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The

obsessions are most frequently focused on the head and face though any body part can be the focus of concern (most often, the skin, hair, and nose), Most patients engage in compulsive behaviors, such as mirror checking, camouflaging, excessive grooming, and skin picking. Psychiatric hospitalization, suicidal ideation, and suicide attempts are relatively common.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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The patient has a serious preoccupation with an aspect of his / her physical appearance that they feel is defective Any part of the body

Facial features are the most commonly involved

Teeth and facial profile

Patient seek corrective treatment Dental treatment may enhance the patients preoccupation

Do not attempt treatment before exploring the patients expectations



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The

doing anything is better than doing nothing approach : this confirms the patients belief of a disease that is nonexistent Beware of litigation !



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Cognitive-Behavioral

Therapy (CBT)

PHARMACOTHERAPY

-SSRIs (Selective Serotonin Reuptake Inhibitors) clomipramine, fluoxetine, fluvoxamine, sertraline, and paroxetine OF 1 & 2Tuesday, August 14, 2012

COMBINATION


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Non-intentional

Severe gout and kidney Epilepsy problems, poor muscle Cerebral palsy control, and moderate mental retardation Autism Lesch-Nyhan syndrome Riley-Day syndrome (familial dysautonomia) Insensitivity to pain, inability to produce tears, poor growth, and labile blood pressure



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Intentional

The only purpose is to play patients role Common feature of depressive disorders

Lesions present at areas accessible to patient Features are inconsistent with the history



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Avoid food so patient is underweight Teenager females Other psychiatric disorders Depression Social phobia Obsessive compulsive disorder

Complications

Malnutrition & dehydration Renal failure & liver dysfunction Amenorrhoea Sialosis



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Binge

eating and purging through vomiting, taking excessive laxatives More common than AN (2% of adult F) Usually normal over body weight Psychological problem

Role

of dentist: recognize condition & referralB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Oesophygeal K+ depletion

erosions

(hypokalaemia) myocardial

instability & Arryhthmias Dental

erosions palatal mucosa

Sialosis Traumatized Nutritional

and haematenic deficiency



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These include: Orofacial manifestations of antipsychotic side effects. Xerostomia Sialorrhoea/ Ptyalism Gingival hyperplasia Lichenoid stomatitis



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Examples are: 1. Haloperidol 2. Chlorpromazine 3. Trifluoperazine The side effects are extrapyramidal



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Orofacial manifestations of antipsychotic side effects Acute dystonic reaction Drug-

induced Parkinsonism dyskinesia

Tardive



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Acute dystonic reactions Movement disorder that causes sustained muscle contraction, repetitive twisting movements with abnormal postures of the trunk, neck, face and limbs. It

is seen within hours or few days following antipsychotic exposure



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Clinical features: Tremor Torticolis Oculogyric crisis Twisting and protrusion of the tongue Dislocation of TMJ(Cenker e tal;2009)



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Diagnosis is based on history of to 1st generation antipsychotics. Treatment

exposure

Review dose of medication Anticholinergic agent

Change to 2nd generation antipsychotics



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Drug induced Parkinsonism Treatment Conventional antiparkinsonism agent of antimuscarinic type( atropine).



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Condition

characterised by persistent, stereotyped, repetitive abnormal involuntary movements of the facial muscles and the tongue associated with chronic exposure to antipsychotic drugs (especially phenothiazine) which bind and blocks the dopamine receptor. Cause is related to dopamine receptor supersensitivity.



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Prevalence

increases with age Common in elderly women People with schizophrenia are vulnerable to developing tardive dyskinesia after exposure to conventional neuroleptics, anticholinergics, toxic substances of abuse and other agents e.g. cigarrettes.



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Subtypes:

Orofacial TD Buccolingual TD Masticatory TD Others Tardive akathisia subjective state of motor restlessness or an aversion to being still.



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Treatment: Use of minimum effective dose of neuroleptics. Discontinue the drug. Reserpine starting with 0.25mg ands gradually increasing to 5.0mg / day.



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Xerostomia Xerogenic drugs of importance in psychiatric practice are: Antidepressants1. TCA( Imipramine) 2. Selective serotonin reuptake inhibitors(SSRI)-Fluoxetin 3. Monoamine oxidase inhibitorsPhenelzineB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Mood stabilizing drug- Lithium carbonate Antipsychotic agents- Haloperidol, Chlorpromazine, Fluphenazine, Risperidone Sedatives- benzodiazepine

Appetite suppressants- fenfluramine, sibutramineB.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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Treatment: Frequent sipping of water Chewing of sugar-free gum e.g Xylitol Secretagogues- Pilocarpine, Cevimeline Saliva substitutes-artificial saliva e.g Orthana, Oralbalance



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Sialorrhoea/Ptyalism Atypical Can

antipsychotic agent- Clozapine.

be ameliorated by Atropine eye drop.



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Gingival hyperplasia Generalized and not related to poor oral hygiene. Anticonvulsant- phenytoin Mood stabilizing drug- Lithium



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Lichenoid drug reaction-

Antipsychotic agent( Phenothiazine) Chlorpromazine

-

Lithium



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Decreased effect of local anaesthesia in alcoholics Increased dose of induction agents in G.A Profound depression of CNS under G.A Sympathomimetic effect of Marijuana potentiates epinephrine in L.A and retraction cord. Lithium and Flagyl or Tetracycline-renal retention of Lithium



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In view of the significant interplay between the mental and oral health( illness), it is most appropriate for the dentists to have an open mind and high index of suspicion while managing patients with underlying emotional disturbance or co-morbid psychiatric disorders. This will make for prompt and accurate diagnosis, proper intervention or referral for psychiatric consultation.B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012

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1. 2. 3. 4. 5. 6. 7. 8. 9.

Tyldesleys Oral Medicine 5th edition by Anne Field and Lesley Longman. David B.Clark. Dental Care for Patients with Bipolar Disorders. J Can Dent Assoc 2003 Terry D.Rees. Oral Effects of Drug Abuse. Crit Rev Oral Biol Med 1992 Irene Cormac, Philip Jenkins. Understanding the importance of Oral health in psychiatric patients. Advances in Psychiatric Treatment 1999 Agbelusi G.A. Psychiatric Disorders in Dentistry. NPMCN Revision Course 2006. Aina O.F. Co-morbid Psychiatric Disorders in Dental Practice. NPMCN Revision Course 2009. Scully C, Bagan- Sebastian J.V. Adverse Drug Reactions in the Orofacial Region. Crit Rev Oral Biol Med 2004 Psychiatry Problems in Dentistry by Ian Macleod and Stephen Potts Jumana Karasneh. Lecture note(Dent 555); Psychogenic Oro-facial Problems



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