Dental Management of Patients with Psychiatric Illness

Question 1

What is mental health?

Answer 1

• a spectrum from minor distress to severe disorders of mind and behaviour
  
  • can be related to substance misuse

Question 2

What is good mental health according to WHO?

Answer 2

” a state of wellbeing in which the individual realises their own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”

Question 3

What percentage of people will experience some form of mental disorder in their lifetime?

Answer 3

50%

Question 4

What can accompany poor mental health?

Answer 4

• high rates of co-morbidity
• reduced life expectancy
  
  • 10-20 years lower for severe cases
• poorer oral health
  
  • erosion
  • caries
  • periodontitis
• hospitalisation
  
  • worst oral health outcomes
  • more susceptible to oral disease
• social withdrawal, isolation and low self-esteem
  
  • worsened by poor oral health

Question 5

What are the impacts of good mental health?

Answer 5

• improved educational attainment and outcomes
• greater productivity and less sickness absence
• improved cognitive ability
• better physical health
• reduced mortality
• increased social interaction and participation
• reduced risk of mental illness or suicide
• reduced risk-taking such as smoking
• increased resilience to adversity

Question 6

What protective factors exist for mental health?

Answer 6

• genetic background
  
  • maternal
    
    • ante-natal
    • post-natal
  • early upbringing
    
    • ACEs
    • attachment patterns
• personality traits
  
  • age
  • gender
  • martital status
• strong social support and networks
• socioeconomic factors
  
  • access to resources
• required inequality
• employment and other purposeful activity
• relationships
• community factors
  
  • level of trust and participation
  • social capital
• self-esteem, autonomy
  
  • values such as altruism
• emotional and social literacy
• physical health

Question 7

Who is at risk of poor mental health in childhood?

Answer 7

• parental use of alcohol, tobacco and drugs during pregnancy
• maternal stress during pregnancy
• low birth weight with impaired cognitive and language development
• poor parental mental health
• parental unemployment
• child abuse and adverse experiences
• use of cannabis

Question 8

Who is at risk of poor mental health in adulthood?

Answer 8

• lower income and debt
• violence
• stressful life events
• housing
• fuel poverty
• unemployment
• suicide
  
  • mental illness
  • physical illness
  • alcohol and drug misuse
• certain personality traits
• experience of abuse

Question 9

What is neuroses?

Answer 9

• anxiety, panic and phobia
  
  • patient retains contact with reality

Question 10

What is dental phobia and how do patient present?

Answer 10

• extreme form of anxiety towards dentistry
  
  • often caused by previous experience
• can be hostile even though they want treatment
  
  • tense and agitated
  • emotional
  • unaware of own anxiety

Question 11

What is generalised anxiety disorder (GAD)?

Answer 11

Regular or uncontrollable worries about many different things in everyday life. Because there are lots of possible symptoms of anxiety it can be a broad diagnosis, meaning the problems experienced with GAD might be quite different between individuals

Question 12

What is panic disorder?

Answer 12

Regular or frequent panic attacks without a clear cause or trigger. Experiencing panic disorder can mean that you feel constantly afraid of having another panic attack, to the point that this fear itself can trigger panic attacks. Can happen even in familiar places and is accompanied by an intense fear something bad is going to happen.

Question 13

What are phobias?

Answer 13

Extreme fears or anxiety triggered by a particular situation or a particular object

Question 14

What can be done to help overcome a dental phobia?

Answer 14

• acclimatisation
• CBT
  
  • can be very effective
• tell, show, do
• stop signals
  
  • gives the patient control
  • requires patience
• needle desensitisation
  
  • show individual components over several appointments
• confidence and reassurance
• painless dentistry
  
  • topical anaesthetic
    
    • requires 5 minutes to properly work
  • take time
    
    • deposit anaesthetic superficially
    • wait until numb
    • inject more

Question 15

What is social anxiety disorder?

Answer 15

Experiencing extreme fear or anxiety triggered by social situations, especially having to talk to other people

Also called social phobia

Question 16

What is post-traumatic stress disorder (PTSD)

Answer 16

Development of anxiety problems after going through something traumatic. Can involve experiencing flashbacks or nightmares which can feel like re-living the fear and anxiety experienced at the time of the traumatic event

Question 17

What is obsessive compulsive disorder (OCD)?

Answer 17

anxiety problems involve having repetitive thoughts, behaviours or urges

Question 18

What is health anxiety?

Answer 18

experiencing obsessions and compulsions relating to illness, including researching symptoms or checking to see if they are present

Question 19

What is body dysmorphic disorder (BDD)?

Answer 19

experiencing obsessions and compulsions relating to physical appearance

Question 20

What is perinatal anxiety or perinatal OCD

Answer 20

some people develop anxiety problems during pregnancy or in the first year after giving birth

Question 21

What is depression?

Answer 21

Depression is characterised by depressed or sad mood, diminished interest in activities that used to be pleasurable, weight gain or loss, fatigue, inappropriate guilt and difficulties concentrating as well as recurrent thoughts of death

Question 22

What factors can contribute to depression?

Answer 22

• stressful events
  
  • relationship breakdown
  • bereavement
• personality traits
  
  • low self-esteem
  • overly self-critical
  • genetic
  • early life experiences
• family history
  
  • closer relative with depression is higher risk
• giving birth
• loneliness
• alcohol and drugs
• illness

Question 23

What are the dental implications of depression?

Answer 23

• chronic facial pain
• oral dysaethesia
  
  • burning mouth
  • sore tongue
• temporomandibular dysfunction syndrome
• delusional oral complaints
  
  • discharges
    
    • fluid/slime
    • powder
  • dry mouth or sialorrhea
    
    • despite normal salivary flow
  • spots or lumps
  • halitosis
  • disturbed taste sensation
• increased caries
• inflamed or infected parotid glands

Question 24

What must a dentist consider when treating a patient with suspected depression?

Answer 24

• dentist may be the first to raise suggestion of depression
  
  • must be approached with sympathy
• delay treatment until depression is resolved
  
  • consider capacity
  • prevention is vital
• care with prescribing drugs
  
  • antidepressants
    
    • interact with BDZ and codeine

Question 25

What is tardive dyskinesia?

Answer 25

• condition as a result of antipsychotic medication
  
  • very difficult to treat
• involuntary movements of the tongue, lips, face, trunk and extremities
• affects around 15-20% of patients
  
  • receiving antipsychotic
    
    • neuroleptics
    • atypical antipsychotics
  • usually over many years
    
    • can occur after short periods
• symptoms are usually mild
  
  • patients may be unaware of symptoms
• doesn’t not respond to withdrawal of causative drug
  
  • no medication to treat

Question 26

What is psychosis?

Answer 26

• umbrella term for many conditions that lose contact with reality
• People lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true

Question 27

What are hallucinations?

Answer 27

when a person hears, sees and in some cases feels, smells or tastes things that do not exist outside their mind but can feel very real to the person affecting them, a common hallucination is hearing voices.

Question 28

What are delusions?

Answer 28

when a person has strong beliefs that are not shared by others, a common delusion is someone believing there is a conspiracy to harm them

Question 29

What are possible causes of psychosis?

Answer 29

• schizophrenia
  
  • condition causing a range of psychological symptoms
  • hallucinations
  • delusions
• bipolar disorder
  
  • mental health condition affecting mood
  • episodes of low mood and high/elated mood
• severe depression
  
  • symptoms of psychosis when very depressed
• traumatic experience
• stress
• drug or alcohol misuse
• side effects of prescribed medicine
• physical condition
  
  • brain tumour

Question 30

What is bipolar disorder?

Answer 30

• patient experiences severe mood swings usually lasting several weeks or months and are far beyond the emotional ups and downs experienced by most people

Question 31

How is bipolar disorder managed and how does it affect dental treatment?

Answer 31

• management very difficult
  
  • delay treatment until stable
• often polypharmacy
  
  • lithium
    
    • multiple interactions (NSAIDS, metronidazole)
    • risk of toxicity
  • xerostomia

Question 32

What are the characteristic components of mania in bipolar disorder?

Answer 32

• feeling very happy
• lots of energy
• ambitious plans and ideas
• spending large amounts of money

Question 33

What are the characteristic components of depression in bipolar disorder?

Answer 33

• feeling very sad, down, empty or hopeless
• very little energy and decreased activity levels
• trouble sleeping, too little or too much
• can’t enjoy anything and feel worried and empty
• having trouble concentrating, forgetting a lot
• eating too much or too little
• feeling tired or slowed down
• thinking about death or suicide

Question 34

What are the dental implications of bipolar disorder in episodes of depression and mania?

Answer 34

• depression
  
  • decline in oral hygiene
  • increased caries rate
  • increased periodontal disease
• mania
  
  • overzealous use of oral hygiene aids
  • abrasion and NCTSL

Question 35

What is schizophrenia?

Answer 35

• disorder of the mind that affects how you think, feel and behave
• distortion of thinking and perception
• loss of social contact, flat mood, inappropriate social behaviour, delusions in oral symptoms

Question 36

What are the positive symptoms of schizophrenia?

Answer 36

• hallucinations
  
  • patient can hear, small, feel or see things
  • most commonly hearing voices
    
    • can be like over-hearing a conversation
    • voices may be talking directly
    • rude, critical, abusive, irritating
  • uncomfortable or painful feelings in body
    
    • touching or hitting
• delusions
  
  • person believes something while other people don’t
  • other people think the person has misunderstood
  • set ideas which cannot be explain
• paranoid delusions
  
  • make the person feel persecuted or harassed
• ideas of reference
  
  • seeing special meanings in ordinary events
  • radio, TV, cars, etc.
• muddled thinking/thought disorder
  
  • harder to concentrate
  • thoughts are disconnected
  • hard for others to understand
• feelings of being controlled
  
  • thoughts have disappeared
  • thoughts are not their own
  • body is taken over

Question 37

What are the negative symptoms of schizophrenia?

Answer 37

• withdrawal or lack of function
  
  • not usual for a healthy person
• start to lose normal thoughts, feelings and motivations
• lose interest in life
  
  • energy and emotions drain away
  • hard to feel excited or enthusiastic
• can’t concentrate
• don’t leave the house
• stop washing, tidying or keeping clothes clean
• feel uncomfortable with people
• hard to understand negative symptoms are real
  
  • not just laziness

Question 38

What are the dental implications of schizophrenia?

Answer 38

• haloperiodol and phenothiazines
  
  • orthostatic hypotension
  • patients raised slowly in dental chair
  • assisted standing
• neuroleptics
  
  • xerostomia
    
    • increased susceptibility to caries and candidiasis
    • can cause ascending parotitis
  • oral pigmentation
  • severe extrapyramidal symptoms
• facial dyskinesias
  
  • bulbar or neck muscles frequently affected
  • difficulties with speech and swallowing
  • can display orofacial dystonia
    
    • uncontrollable facial grimacing
• haloperidol and clozapine
  
  • hyper salivation

Question 39

What is schizoaffective disorder?

Answer 39

A disorder of the mind that affects thoughts and emotions and may also affect actions. Patients may experience episodes that are combinations of both psychotic symptoms and bipolar disorder symptoms. These symptoms are clearly present for most of the time over a period of at least two weeks.

Essentially a midpoint between bipolar and schizophrenia but dental implications are similar to that of schizophrenia

Question 40

What are eating disorders?

Answer 40

severe persistent disturbance in earring behaviour associated with distressing thoughts and emotions

Question 41

What kind of people are most likely to be affected by eating disorders?

Answer 41

• around 5% of the population
• more common in females
• usually develops in adolescence
• associated with preoccupation with food, weight or shape accompanied by anxiety about eating or consequences of eating certain foods

Question 42

Provide examples of eating disorders

Answer 42

• anorexia nervosa
• bullimia nervosa
• binge eating disorder
• avoidant restrictive food intake disorder
• PICA/rumination disorder

Question 43

What is anorexia nervosa?

Answer 43

• self starvation and weight loss
  
  • results in low weight for height and age
• highest mortality rate of any psych disorder
  
  • other than opioid sue
• BMI under 18.5
• diet driven by intense fear of gaining weight or becoming fat
  
  • restrictive type
    
    • weight loss by diet, fasting, excess exercise
  • binge eating/purging
    
    • intermittent bing/purge
    • on top of diet, fasting and exercise

Question 44

What are the signs and symptoms of anorexia nervosa?

Answer 44

• no period
  
  • females
• dizziness and fainting
  
  • due to dehydration
• brittle hair and nails
• cold intolerance
• muscle wasting
• GORD
• constipation
• stress fractures
  
  • from exercising
• osteopenia and osteoporosis
• depression and anxiety
• poor concentration
• lanugo hair
  
  • fine soft hair across body
• hypokalaemia
• hypotension
• hypothermia
• arrhythmia
• cardiac atrophy
• sudden cardiac death

Question 45

What is bulimia nervosa?

Answer 45

• alternate dieting with binging on forbidden foods
• binging
  
  • eating a large amount of food in a short period of time
  • associated with feelings of losing control
  • usually secretive
    
    • feelings of embarrassment and shame
  • occur weekly for at least 3 months
  • followed by compensatory behaviours
    
    • fasting
    • vomiting
    • laxative misuse
    • exercise
• excessively preoccupies with thoughts of food, weight and shape which negatively impact life and self worth
• can be underweight or obese
• cyclical pattern
  
  • unrealistic goals set
  • goals not met so binging occurs
  • ‘fix’ binge by purging

Question 46

What are the signs and symptoms of bulimia nervosa?

Answer 46

• frequent bathroom trips after meals
• large amount of food disappearing/empty wrappers
• chronic sore throat
• sialosis
• caries/erosion
• GORD
• recurrent, unexplained diarrhoea
• dizziness and fainting
  
  • due to purging and dehydration
• mouth ulcers
• Russels sign
  
  • calluses on knuckles
  • as a result of inducing vomiting
• Mallory-Weiss syndrome
  
  • tearing of GIT
  • bleeding in vomit
• halitosis
• diabetes mellitus
• fatal oesophageal tear
• gastric rupture
• cardiac arrhythmia

Question 47

How can bulimia nervosa be managed?

Answer 47

• CBT
• anti-depressants
  • fluoxetine SSRIs

Question 48

What is binge eating disorder?

Answer 48

• most common eating disorder
• consumption of a large quantity in a short time frame
• no compensatory behaviour

Question 49

What are the signs and symptoms of binge eating disorder?

Answer 49

• eating more rapidly than others
• eating until uncomfortable
• consuming large quantities of feed when not hungry
• eating alone
  
  • embarrassed by how much is being eaten
• disgusted/depressed/guilty
• obesity
• diabetes
• hypertension
• cardiovascular diseases

Question 50

How can binge eating disorder be managed?

Answer 50

• CBT

Question 51

What is avoidant restrictive food intake disorder (ARFID)?

Answer 51

• disturbance in eating resulting in persistent failure to meet nutritional needs
  
  • extremely picky eating
• not concerned about weight or shape
• avoidance or limitation can be due to:
  
  • lack of appetite or interest in eating
  • extreme avoidance due to sensory characteristics
    
    • texture
    • smell
  • anxiety or concern about consequences of eating
    
    • choking
    • nausea
    • committing
    • allergy
    • previous event (food poisoning/choking)

Question 52

What are the dental implications of bulimia nervosa?

Answer 52

• dental erosion
  
  • lingual, palatal and occlusal surfaces
  • rinse with bicarbonate of soda and water after vomiting
• angular chelitis
• glossitis
• candidiasis
• oral ulceration/lacerations/petechiae
  
  • due to induced vomiting
• sialosis
  
  • parotid swelling
    
    • subsides once weight has increased
• xerostomia
  
  • dehydration
  • antidepressant medication
• poor oral hygiene, caries and periodontal disease
  
  • consumption of sugar and carbohydrate rich foods
  • may be unlikely to seek dental treatment
    
    • do not want to talk about teeth
  • important to prevent further tooth loss
  • prescription of higher fluoride toothpaste
• dental hypersensitivity
  
  • due to erosion
  • fluoride trays
  • fluoride varnish
• risk of pathological fracture
  
  • reduced bone density
• fatigue
  
  • mental
  • physical
• memory loss
  
  • difficulty remembering appointments
• attendance
  
  • avoid appointments close to meal times
  • may be distressed
  • do not give diet advice

Question 53

What are the dental implications of anorexia nervosa?

Answer 53

• attendance
  
  • do not schedule appointments around meal times
  • can use as an excuse to avoid eating
• prescribing medications
  
  • must consider a lowered dose for lower weight
  • especially painkillers
• local anaesthetic
  
  • must consider dose limitations for bodyweight
• restorative work
  
  • best left until patient has recovered if complex
  • can cary out non invasive composite restorations
    
    • prevents further deterioration of the dentition
• IV sedation and general anaesthetic
  
  • contraindicated until patient is recovered
• full coverage plastic splints

Question 54

How can dentists help patients with eating disorders?

Answer 54

• offering a safe space for the patient to open up
  
  • do not lecture or scrutinise diet
• offer simple facts as to what has caused the problem
  
  • tooth erosion
    
    • acidic foods
    • acidic drinks
    • reflux
    • vomiting
• signposting to appropriate services
  
  • if patient discloses information
• offer support and regular appointments
  
  • review dentition
  • only carry out essential dental treatment
• treat patient as medically compromised
  
  • consider the physical and mental impact

Question 55

What is the SCOFF Questionnaire?

Answer 55

• Sick, Control, One stone, Fat, Food questionnaire
• designed to aid diagnosis of patients with potential eating disorders
  
  • yes to 2/5 or more indicates eating disorder
• SCOFF questions
  
  • do you believe you are fat when others say you are thin?
  • do you worry that you have lost control over how much you eat?
  • do you make yourself vomit because you feel uncomfortably full?
  • would you say that food dominates your life?
  • have you recently lost more than 15lbs in a 3 month period

Question 56

Why might accessing a dental clinic be challenging for patients with mental health conditions

Answer 56

• if outpatient living in the community
  
  • poor time keeping
  • poor attender
  • chaotic lives
  • cost
  • geographical location
  • transport
  • late fees
  • home address
• if an in patient in a department
  
  • reliant on hospital staff to bring them to appointments
  • may not be well enough to attend

Question 57

Why might a medical history be more complex for a patient with a mental health condition?

Answer 57

• difficult to obtain
  
  • confidentiality
• more likely to have multiple co-morbidities
• polypharmacy
  
  • side effects
  • drug interactions
• challenging mood
  
  • agitated
  • suspicious
  • demanding
  • manipulative
  • scared/fearful

Question 58

What may be seen on examination of a patient with a mental health condition?

Answer 58

• poor oral hygiene
• poor cooperation
• smoker
• self-neglect
• low salivary flow rate
• high risk of caries, periodontitis and oral cancer
• tardive dyskinesia
• candida and denture induced stomatitis
• trauma
• cancerous or pre-malignant lesion
• xerostomia
• poor denture hygiene

Question 59

How might a patient having a mental health condition impact treatment planning?

Answer 59

• must always be realistic
  
  • type, severity and stage of illness
    
    • acute or chronic
  • patient mood and motivation
    
    • best time of day or day of the week
  • patients perceptions of their oral health
  • habits and lifestyle
  • ability to self care
    
    • discharge may result in old habits returning
  • patient’s wishes
    
    • liaise with staff and family also
  • complex dental work may not be right for the patient
• make dentally fit and able to function
  
  • while mental health not stable
  • treatment can be slow and frustrating
• mindful of prevention provided
  
  • alcohol containing mouthwash
  • dental floss
  • wooden sticks
• prescribing
  
  • many drug interactions
• endodontics
  
  • consider 1 stage
• motivation
  
  • usually constantly required
• offer high quality care
  
  • no judgement
  • do not over treat

Question 60

How does a patient having a mental health condition potentially impact on providing treatment?

Answer 60

• universal precautions
• lone working policy
  
  • nobody should ever be alone with the patient
• consent
  
  • poor understanding
  • short attention span
  • ignorant of dental problems
  • unrealistic expectations of what can be achieved
  • beyond normal reasoning
  • unreliable or forgetful
  • medications altering behaviour and memory
  • avoid irreversible treatment while patient is under acute care

Question 61

How can candida infections be managed in patients with metal health conditions?

Answer 61

• oral hygiene instruction
• denture hygiene advice
• new denture construction
• antifungals
  • chlorhexidine mouthwash or gel
  • miconaxole (topical)
  • fluconazole (systemic)
  • nystatin

Question 61

How does a patient having a mental health condition affect their ability to access sedation and general anaesthetic?

Answer 61

• difficult to access in general
• many have tolerance to sedative drugs
• conscious sedation services are more easily accessed than GA

Question 62

How can xerostomia be managed in patients with mental health conditions?

Answer 62

• affects chewing, swallowing, speech, taste and overall quality of life with an increased risk of caries, periodontal disease, candida, sialadenitis and prosthetic difficulties
• oral gel, lubricants or emollients
  
  • petrolium jelly based products or cetraben
  • used to coal and protect the soft tissues
• pilocarpine HCl
  
  • enhances salivary secretions
  • oral administration (5mg 3 times daily)
  • improvement declines after cessation
  • can cause sweating, headache and urinary frequency
• sugar free chewing gum
  
  • requires some salivary function
  • limited evidence base
• acidic pastels
  
  • used with caution due to tooth erosion
    
    • Salivix
• frequent sips of water
• salivary replacements
  
  • difficult to replicate
  • Glandosane
    
    • avoid for dentate patients due to acidic pH
  • gels
    
    • may have a longer duration of benefit
  • many contain animal derivatives and allergens
    
    • saliva orthana - porcine mucin, fluoride
    • biotene oral balance - milk, egg white
    • bioxtra gel - milk, egg white, fluoride

Question 63

What barriers exist for patients with mental health problems accessing dental care?

Answer 63

• attitudes to oral health
• attitudes to patient group
• lack of education
• cost
• manpower
• poor access to specialist services

Question 64

What recommendations can be made when interacting with patients with mental health conditions?

Answer 64

• active listening
• enquire about life history
• talk about current and future expectations
• allow for questions and discussion
• discuss all possible treatment options
• discuss possible side effects of medication
• bring someone to the appointment
  
  • remind the patient they can be accompanied
• work with carers
  
  • can provide helpful advice and information
• avoid jargon
  
  • use language that is easier to understand
• manage expectations
  
  • set realistic timelines
• letter copies
  
  • for patient
  • for carer
  • explain any jargon present