Download Psychiatry & Dentistry II

Psychiatry & Dentistry II
Fahad Alosaimi MBBS, SSC-Psych
Consultation liaison psychiatrist
King Saud University
Introduction
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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.
Outlines
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Chronic idiopathic facial pain.
Body dysmorphic disorder (BDD).
Oral ulceration.
Anorexia nervosa and bulimia.
Dental phobia.
Chronic idiopathic facial pain
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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
Clinical features of Chronic idiopathic facial
pain
Symptom
complexes
Clinical features
facial
arthromyalgia
(FAM)
uni- or bilateral pain in the temporomandibular joint (TMJ) and
associated craniofacial musculature, and there may also be a sense of
fullness, popping, or tinnitus in the ear
Atypical facial a continuous ache with intermittent excruciating episodes, localized to
pain (AFP) (or the non muscular, non joint areas of the face. The pain may be uni- or
idiopathic
bilateral and may persist for months or years.
facial pain)
Clinical features of Chronic idiopathic facial
pain
Symptom complexes
Clinical features
Atypical odontalgia
(AO)
the dental variant, which is diagnosed in the
absence of detectable dental pathology.
Oral dysesthesia
includes a burning discomfort in the tongue (glossopyrosis),
gingiva, or lips; a persistently dry mouth in the
presence of saliva; a disturbance of taste; denture
intolerance; or a persistently uncomfortable
occlusion (phantom bite or occlusal hyperawareness).
Clinical features of Chronic idiopathic facial
pain
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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
ETIOLOGY of Chronic idiopathic facial pain
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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.
ETIOLOGY of 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
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psychologically vulnerable subject →
(release of neuropeptides in the "target tissues" such as the joint
capsule, muscles, periodontal membrane, or dental pulp)
TREATMENT
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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.
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Medications :
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Tricyclic antidepressant e.g nortriptyline.
*S/E: Drowsiness and xerostomia, weight gain and constipation.
SSRIs e.g. Fluoxetine.
Cognitive therapy ± drugs.
Hypnosis.
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Course & prognosis
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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.
BODY DYSMORPHIC DISORDER
(BDD)
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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.
Types of BDD
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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.
Risk factors of BDD
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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 .
Treatment of BDD
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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.
ORAL ULCERATION
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Aphthous ulcers: shallow, painful oral ulcers.
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Etiology : unknown ? autoimmune disturbance ? emotional
problems may precipitate their lesions.
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Management:
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Ulcer diary :
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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.
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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.
ORAL ULCERATION
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Factitious ulceration (stomatitis artifacta).
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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.
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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.
Anorexia nervosa and bulimia
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Anorexia nervosa is 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.
Dental phobia
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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 .
Risk factors of Dental phobia
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Anticipating pain
Uncertainty about particular treatments
Bad previous experience
Females
Lower school education
Lower social classes
Dentist's behaviour
Biological propensity to develop anxiety.
Prevention of Dental phobia
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Public dental health education
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Dental Care need to be :
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long-term
frequent
regular
by one dentist
including sessions devoted purely to educational
aims, perhaps conducted in small groups.
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Management of Dental phobia
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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.