PSYCHIATRIC PROBLEMS IN DENTISTRY

1
PSYCHIATRIC PROBLEMS IN DENTISTRY

• By
• Iain Macleod
• Stephen Potts

2
Royal Bethlehem Hospital Bedlamc18th
3
Classification of psychological disorders

• Neurosis
• Psychosis
• Disorders of personality and behaviour
• Substance misuse
• Learning disability
• Organic problems

4
Neurosis v Psychosis

• Schizophrenia,Manic Depressive illness
• Qualitatively different
• Delusions Hallucinations Thought disorder
• Rare

• Anxiety, Depression, Somatisation
• Quantitatively different
• Excessive degrees of normal phenomena
• Common

5
Dental presentation - Psychosis

• Aliens are controlling me through transmitters
  implanted under my fillings..
• I want them out.

6
Dental presentation Neurosis

• Look at my tongue. Im really worried its
  cancer. I know you said before its not, and I
  felt better for a while, but I cant stop
  thinking about it, especially since that man on
  the telly said it was on the increase.
• I want you to check me out again and this time I
  want a scan.

7
Anxiety and depression(emotional disorders)

• Both are extensions of normal emotions
• Signs and symptoms of anxiety are due to
  sympathetic overactivity fright/fight/flight
  response
• Anxiety due to specific trigger phobia
• Generalised anxiety anxiety trait
• Severe form panic attack
• Can get combined anxiety and depression

8
pathophysiology
TRIGGER
SYMPATHETIC ACTIVITY
HYPERVENTILATION
PANIC
RESPIRATORY ALKALOSIS
CATASTROPHIC INTERPRETATION
BODY SENSATIONS
9
Depression

• Various sub-types
• Unipolar and bipolar (with mania)
• Can be acute or chronic
• Genetic factors may be present (family history)
• Can lead to suicide
• Can be difficult to detect
• Patients may lack insight
• May not seek help feel unworthy

10
Ten key symptoms of depression

• Depressed mood (forgt2weeks)
• 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 (eg.early morning waking)
• Appetite and weight change (usually lost)

11
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

12
Life events scale
13
Somatisation

• Somatisation has been defined as the expression
  of personal and social distress in an idiom of
  bodily complaints, with medical help seeking

14
Common !

• In general medical practice,somatisation
  associated with psychiatric illness accounts for
  20 - 30 of all consultations
• Higher in specialist clinics (50 or more)

15
Why the mouth ?
Sensory cortex
16
Theoretically,every disease is
psychosomatic,since emotional factors influence
all body processes through nervous and humoral
pathways
Franz 1950
17
PAIN

• Pain is an unpleasant sensory and emotional
  experience associated with actual or potential
  tissue damage or described in terms of such
  damage
• - pain is always subjective -

Int. Assoc. for the Study of Pain
18
PAIN

• Pain is a complex sensation
• Pain can cause considerable distress
• chicken and egg situation
• Dental pain can be difficult to diagnose
• Beware of referred pain (sinuses,cervical
  spine,heart etc.)

19
KEY QUESTIONS

• Is the pain present every day ?
• What is a normal day like ?
• How severe is the pain ? (score 0 10)

20
Rules of thumb !

• Dental pain gets better or worse !
• Chronic pain is rarely dental
• If an experienced dentist feels the pain is not
  dental they are most often right

21
Assessment tools

• Visual analogue scale

/
0
10
cm
No pain
Severe pain
- Verbal rating scale
Eg. How are things at present ?
0 could not be better
10 could not be worse
22
Orofacial pain conditions

• Atypical facial pain
• Atypical odontalgia
• Oral dysaesthesia
• Phantom bite syndrome
• (TMD)
• Syndrome of bizarre oro-facial symptoms

23
Atypical facial pain

• Middle aged or older
• Mainly female
• Constant pain / discomfort
• Poorly localised
• May cross midline
• Does not waken patient from sleep
• Lack objective signs
• Investigations (-ve)
• Other symptoms (headaches,IBS,backache etc.)

24
Atypical facial pain

• Demand physical treatment
• Often do not accept psychological explanation
• May have seen several specialists/practitioners
• May be obsessed with symptoms

25
Management

• History
• Exclude organic disease
• HAD scale
• Life events counselling
• medication / referral

26
Role of the dental practitioner

• Explanation of these common conditions
• Allow patients to express their concerns and
  beliefs as to what is happening
• Reassure re. cancer phobia
• Reduce fear of the need for surgery
• Explanation of parafunction
• To refer appropriately

27
Role of psychologist/psychiatrist

• Detailed history
• Explore connections to life events
• Assess for psych disorders (depression)
• Minimise iatrogenesis
• Treat medication (antidepressants)
• Treat psychological (CBT, CPN)
• Treat social (support, links)
• Liaise GDP, GMP, other specialists

28
Body dysmorphic disorder

• An obsessive concern about a body part or
  appearance
• Will seek physical intervention
• Unlikely to be pleased with results and demand
  further treatment
• May become depressed
• Will not accept a psychological explanation

29
Wrong !

• The doing anything is better than doing nothing
  approach this confirms the patients belief of a
  disease that is non-existent
• Beware of litigation !

30
The scream
Edvard Munch 1863-1944