Psychiatry & Dentistry II

1. Psychiatry & Dentistry II Fahad Alosaimi MBBS, SSC-Psych Consultation liaison psychiatrist King Saud University

2. Ms. Sarah Sarah is 19 years old, girl, university student. She presented with a strong feeling of having an ugly appearance of her teeth despite multiple orthodontic procedures. Her teeth appearance looks OK for you. She insisted you do one more correction. How can you manage?

3. 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 ++ inappropriate 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.

4. Outlines • Classification of mental disorders. • Chronic idiopathic facial pain. • Body dysmorphic disorder (BDD). • Oral ulceration. • Anorexia nervosa and bulimia. • Dental phobia.

5. General classificationNeurosis versus Psychosis

6. The Diagnostic and Statistical Manual (DSM) classification of mental disorder (365 disorders) Disorders usually first diagnosed in infancy, childhood, or adolescence. Delirium, dementia and amnestic, and other cognitive disorders. Mental disorders due to a general medical condition. Substance – related disorders. Schizophrenia and other Psychotic disorders. Mood disorders. Anxiety disorders. Somatoform disorders. Factitious disorders. Dissociative disorders. Sexual and gender identity disorders. Eating disorders. Impulse – control disorders. Adjustment disorders. Other conditions that may be a focus of clinical attention.

7. 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

8. Clinical features of Chronic idiopathic facial pain

9. Clinical features of Chronic idiopathic facial pain

10. Clinical features of Chronic idiopathic facial pain • AFP and AO often coexist or occur sequentially in the same patient. • Chronic idiopathic facial pain is associated with: • other chronic pains such as headache, neck and back pain • fibromyalgia • pruritus • abdominal pain (irritable bowel) • pelvic pain • myalgic encephalomyelitis • PTSD. • The overview creates a picture of a pain-vulnerable person or a whole body pain syndrome

11. ETIOLOGY of Chronic idiopathic facial pain • Idiopathic. • Both psychosocially and biochemically vulnerable. • 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 • One study : 43% of such patients were psychiatrically normal, 35% had a depressive illness, and 22% were diagnosed as mixed neurosis cases. • A small number : personality disorder with marked somatization or psychosis.

12. ETIOLOGYof Chronic idiopathic facial pain PET : increased contralateral cingulate cortex activity in response to both heat and nociceptive heat. This suggests an enhanced alerting mechanism in response to peripheral stimuli which could therefore be perceived as pain. In summary: emotional strain + local physical stress + biochemically and psychologically vulnerable subject→ (release of neuropeptides in the "target tissues" such as the joint capsule, muscles, periodontal membrane, or dental pulp)

13. 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.

14. Course & prognosis 70% of patients respond to appropriate history taking and medication. Chronic course because of both a biochemical and psychological trait basis. Patients need continued care as in cases of migraine or trigeminal neuralgia.

16. 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.

17. Types of BDD Ethnic dysphoria : Dissatisfaction with ethnic features , first vocalized in early adolescence. Sexual or gender dysphoria: an obsessional need to change gender ( e.g. reducing the masculine features of a male transsexual). Treatment in collaboration with a unit specializing in the appropriate psychiatric, dental, hormonal, and surgical sexual realignment.

18. Risk factors of BDD • Emotionally sensitive • Socially isolated • Introverted individuals with no sexual experience • Environmental stresses such as employment problems, difficulties in personal relationships • Acute events such as bereavements. • A morbid affective state such as depression .

19. 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.

21. ORAL ULCERATION • Aphthous ulcers: shallow, painful oral ulcers. • Etiology : unknown ? autoimmune disturbance ? emotional problems may precipitate their lesions. • Management: • Ulcer diary : • When patients complain of recurrent crops of painful ulcers. • Patient notes the number of ulcers present in the mouth and any associated factors on a day-to-day basis. • Ttricyclic antidepressant will often produce a marked reduction in the number, frequency, and duration of the ulcers, making them more amenable to topical steroid therapy.

22. ORAL ULCERATION Factitious ulceration (stomatitis artifacta). The history is vague and the lesion either persists longer or recurs more frequently than one would expect. The most common lesion is due to cheek chewing( bilateral and painless). Unfortunately, there appears to be no age, intellectual, or professional barriers( ?medical background) to this problem. Women more prone than men. It is often associated with one of the pain syndromes.

23. Types of Factitious ulceration 1. True malingerers, where the injury is consciously aggravated for monetary gain or the avoidance of some responsibility. 2. Munchausen's syndrome, which is a persistent, incurable psychopathic way of life that offers no obvious advantage other than requiring medical and nursing care. 3. Part of an emotional instability, such as a personality disorder, where the underlying problem is a disturbance in personal relationships. It is important to protect the patient from inappropriate investigations and treatment.

24. Anorexia nervosa and bulimia Anorexia nervosais 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.

25. Dental phobia

26. 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 .

27. Dental phobia (vicious cycle)

28. 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.

29. 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.

30. 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.

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32. Thank you