Psychiatric Disorders— Practical Aspects
There are many ways mental health and oral health can impact each other. Medications used to treat mental illness may interact with drugs used in dentistry. Some oral health problems arise from the manifestations of mental illness, while others may be side effects of psychiatric medications. Unfortunately, patient psychiatric disorders also produce reduced rates of compliance for preventive oral health care, as well as a reduced ability to obtain and tolerate needed oral health treatment. For patients with severe or chronic mental illness, this combination of greater susceptibility to oral health problems and difficulty with oral health maintenance can be devastating. (See case example A: “Can You Help Me with my Teeth?”) Working with oral health care professionals who understand the practical aspects of patients’ oral health care can have tremendous payoffs for these patients. Most patients whose emotional problems affect their oral health care can be helped by oral health professionals who are knowledgeable and sensitive. (See case example B: “Terrified.”)

Oral health conditions associated with mental illness
Certain oral health conditions are virtually diagnostic of a specific mental illness and some have a poorly understood association with mental illness. Others can indicate a personality type or a medication side effect. Atypical odontalgia demonstrates that inexplicable symptoms should not automatically be ascribed to mental illness.5

Enamel erosion, especially diagnostic if the pattern of erosion is on the lingual surfaces of the anterior maxillary teeth, can be an indication of self-induced vomiting, a characteristic of bulimia nervosa and sometimes anorexia nervosa (Figure 1). Patients with an eating disorder also may have increased dental caries, tooth hypersensitivity, margination of restorations, osteoporosis, cardiac abnormalities, muscle cramps, and numerous other health problems. Referring such individuals to a mental health professional, with permission of the patient, can be a service to those who have these serious, potentially life-threatening diseases.6-8

Gingival recession and tooth abrasion can result from aggressive brushing, often a characteristic of perfectionists. Since these individuals are generally eager to please, overzealous brushing may be readily corrected with an explanation from the dental hygienist of the harmful effects.9 On the other hand, these signs can also indicate mania or, in rare cases, cocaine abuse in the form of rubbing on gingival.10

Xerostomia is often seen in patients with mental illness. It can be associated with bulimia, depression, anxiety, systemic diseases, including diabetes, dehydration, and rheumatoid arthritis, or radiation treatment to the head or neck region. It is often a side effect of medications. 11 Some of these medications are antidepressants, antipsychotics, sedatives, and hypnotics (Figure 3). The clinical sequelae of chronic, untreated xerostomia can be severe, including oral infection, inflamed, fissured tongue, glandular enlargement and infection, rampant caries, and enamel erosion.

Some patients who take psychotropic medications to improve their quality of life, risk lowering that quality if oral health problems are ignored. More than 400 medications, including most psychotropic drugs, cause xerostomia. For the patient with medication-induced xerostomia, effective, less xerostomatic, alternative drugs may be available; consultation with the patient’s prescribing physician and pharmacist can be helpful. Preventive oral health maintenance with regular recall visits and meticulous oral hygiene is key. Temporary symptomatic relief may be obtained from sipping water and from products specifically formulated to relieve dry mouth symptoms, such as Biotene® mouthwash and dry mouth gum, Natrol DMR (Dry Mouth Relief)® and Roxane® Saliva Substitute. OralBalance® gel and Biotene® toothpaste from Laclede® have been shown to improve gingival health in xerostomatic patients.12

A typical odontalgia (AO) is an oral pain disorder that, if misidentified, can lead to unnecessary, irreversible treatment. AO is characterized by chronic throbbing or burning pain in the teeth, alveolar process, or mucosa without a clear cause. According to early reports, AO was thought to be a manifestation of psychiatric disorder.13 However, recent investigations indicate that the pain of AO is primarily neuropathic, that is, it originates from sensitization of nerves, often following oral health treatment.14 There was lack of knowledge concerning neuropathic pain until recently. Therefore, neuropathic pain is a relatively new term to many oral health care and medical professionals.5 The danger of AO is in misdiagnosis. The moderate to severe pain of AO may mimic dental disease sufficiently to prompt deadening or extraction of teeth without providing lasting relief for the patient.15

Although mental illness does not cause AO, this oral pain disorder is associated with depression or other psychiatric disorders, perhaps because the perception of pain is affected by the emotional state. Patients who have symptoms consistent with AO can be referred to a specialist pain center to test specifically for pain of neuropathic origin, as well as other forms of pain. Testing by a specialist may spare patients extensive and unnecessary dental treatment.14 It can be expected that making a differential diagnosis between atypical odontalgia and somatoform disorder with pain symptoms will lead many more patients to appropriate and effective treatment for their pain.

Temporomandibular disorders (TMD) involve the joints and/or muscles active in chewing. Pain, limited range of jaw motion, and temporomandibular joint noises are common symptoms. Several studies have shown an association between TMD and mental illnesses such as depression, anxiety, and substance abuse.16-18

It is not yet clear which comes first—mental illness or TMD. Life stressors related to mood disorders may lead to facial muscle tension, bruxism, etc., which then leads to TMD.19,20 On the other hand, the pain and stress associated with TMD may contribute to mood disorders. In any case, oral health care personnel should be aware that about half of individuals with TMD have or have had a mood disorder or other psychological diagnosis, especially patients whose symptoms are primarily muscle- and pain-related, as opposed to joint-related.17,18.

Bruxism, as mentioned above, may be related to stress or it may provide a means of coping for patients with constant intraoral pain.14 It can even be a side-effect of antipsychotic and antidepressant medication.21 If this is suspected, consultation can alert the prescribing physician to evidence of bruxism seen on oral examination.

Factors that Affect Treatment Delivery
In addition to the behavioral aspects of psychiatric disorders (discussed later), factors that can affect treatment include neuromuscular side effects of medications, mitral valve prolapse (often associated with panic attacks), medication interactions, and alterations in pain threshold.

Some psychotropic medications can cause movement disorders that damage teeth or interfere with oral health care. Extrapyramidal side effects (EPS) often arise from the neuroleptic-antipsychotic drugs. Early effects can include muscle spasms of the face, tongue, and neck. A Parkinson’s-like syndrome—including slowed movement, rigidity, tremor, and restless movement— can occur days or weeks after initiation of therapy.22 Since these effects are most commonly seen when the medications are started or the dosage is increased, oral health care appointments can be planned to avoid times when a patient's medications are being adjusted.

Tardive dyskinesia is a lateappearing side effect of neurolepticantipsychotic medications which occurs in 20 to 40% of patients taking high doses of these medications long-term. The characteristic sign of tardive dyskinesia is orofacial dyskinesia—an involuntary movements of the tongue, face, or jaws. Involuntary trunk and limb movements also may occur. Unfortunately, unlike the early appearing side effects of these medications, tardive dyskinesia is difficult to reverse once it has appeared, although it may resolve after months or years.23 The uncontrolled oral movements can interfere with oral health care treatment. Some control of the dyskinesia with medication adjustment may be possible; consultation with the patient’s prescribing physician and pharmacist can be helpful. Note that the newer antipsychotic drugs now available (the atypical antipsychotic drugs) are believed to cause tardive dyskinesia less frequently.23

Patients with panic disorder may have mitral valve prolapse as well. Mitral valve prolapse (MVP), an abnormality of one of the heart valves, is often benign, causing no symptoms. However, significantly more patients with panic disorder or agoraphobia have coexisting MVP.24,25 Dental hygienists need to be aware of this condition, since prophylactic antibiotics are recommended before therapy that involves gingival bleeding that could result in exposure to transient bacteria in the bloodstream. To avoid potential cardiac complications, a cardiology consultation is advisable in patients with panic disorder to rule out MVP or to arrange appropriate preventive antibiotic therapy if it is present.26

The potential for interactions between medications used to treat mental illness and medications used in dentistry is a consideration whenever anesthetics or other drugs are used. Figure 4 provides information on potential drug interactions and side effects.

Orthostatic hypotension is a side effect of some medications used to treat mental illness; patients who have this symptom will need to have position changes (horizontal to vertical) made more gradually than usual to avoid dizziness or faintness.27

Pain perception in patients with mental illness may vary. Depressed patients, for example, may be especially sensitive to pain, as may patients with a history of substance use. (See below: “Working with Patients who have Severe or Chronic Mental Illness”). In contrast, patients with schizophrenia may have difficulty recognizing pain when it is present. One should be sensitive to these potential differences in pain perception and provide pain control as needed.

Working with fearful, phobic, suspicious, and cognitively impaired patients

Fear and distrust are common in patients receiving oral health care, especially in those with mental illness. Patients who are fearful and suspicious call for specific responses in oral health care personnel (Figure 5). Case example A illustrates a patient whose schizophrenia did not interfere with her ability to accept gentle oral health care. At the time she received this care, she was in a mental health treatment program and stabilized on medications. The second example is of a fearful patient who was treated in the second author’s office. For patients whose problems with dental phobia seem beyond the expertise available, referral to a clinic specializing in treatment of such patients or working with a professional specializing in treatment of fears and phobias are helpful options.

The patient with a history of sexual abuse may not be aware of this history. The dental hygienist or other oral health care professional may suspect such a history if the patient develops sudden, inexplicable anxiety in response to such actions as lowering the back of the dental chair or working in the oral cavity. For any patient who becomes anxious, it is important to stop working, give control to the patient, and proceed only with the patient's explicit permission and at a pace that is comfortable for the patient. For severe or recurring anxiety, referral is advisable.

Cognitive impairments vary, but often patients with dementia have good recall for the distant past and for the past 15 to 20 minutes. For some patients, a reintroduction to the personnel and the procedures may be necessary if they take longer than the 15 to 20 minute window of shortterm memory. Instructions should be kept short and simple. Provide written instructions for the patient to use at home, and work in conjunction with family members or others who are helping with daily activities.