Article Type : Opinion Article
Authors : Shunmugavelu K, Javid Shaikh SM and Joseph R
Psychiatric or mental
disorders are described as a medical condition that disrupts an individual's thinking,
feeling, mood, ability to relate to others, and daily functioning. The change
in mental awareness may often result in a diminished capacity for coping with
the ordinary demands of life. Often this inability to deal with day to day
tasks includes oral self-care [1].
Mental disorders in
children are described as series of changes in the way they behave or handle
emotions causing distress and problems getting through the day. Mental
disorders most seen in children are Anxiety, Depression, Obstructive Compulsive
Disorder (OCD), Attention Deficit Hyperactive Disorder (ADHD), Tourette
syndrome, Substance abuse disorder (SUD) etc [2]. In a study conducted it was
found that girls showed a higher number of cases of depression and anxiety
disorders. It was seen that boys aged 9 to 10 years showed 3.6% ADHD disorders,
5.5% Tourette disorders, 4.1% substance abuse disorder. The incidence reduced
by 50% by age of 11 years and disappeared by age 16 years. The move into
adolescence showed rise in rates of depression and social phobia in girls which
was not seen in boys. Middle of adolescence showed increase in substance use
disorders in both sexes. A recent British population study of youth age 5 to 15
years short prevalence of anxiety disorders by 3.8%, depression by 10.9%, ADHD
1.4%, ODD by 2.9%, tic disorder by 0.1% [3]. A detailed explanation of the
mental disorders with their oral signs and symptoms are illustrated which would
give a deeper insight for a better treatment planning of the patients.
Depression and anxiety
are recognized as significant mental health problems during childhood and
adolescence [4]. Anxiety is defined as a state of heightened alertness to signs
and symptoms of autonomic excitation. There is constant fear of danger even in
absence of danger [5]. Anxiety can be presented as signs of severe agitation
and tremors, heart pounding, have trouble breathing or dizziness. Typically
occurs in young children when they do not outgrow fears which can interfere in
their day-to-day activities. Separation anxiety, fear of school, future or bad
things happening can cause panic disorders or repeated episodes of sudden
intense fear. They might be irritable or angry and might experience trouble
sleeping [2,5]. Depression is a frequent and debilitating disorder
characterized by loss of energy, inability to concentrate or feeling of sadness
and hopelessness which interferes with daily activities of individuals [5]. The
prevalence of symptoms of anxiety and depression increases during development;
these problems are associated with impaired social and school functioning.
Infants and preschoolers
do not have the ability to express feelings of sadness in language. Therefore,
depressive symptoms must be inferred from overt behavior, including apathy,
withdrawal from caregivers, delay or regression of developmental milestones and
failure to thrive that has no organic cause. Because of the difficulties of
diagnosing any psychiatric disorder in this age group, clinicians must rely
heavily on parental history, evaluation of parent-child interactions and play
interviews by appropriately trained professionals. For school children, their
teachers can also serve as a valuable source of information and should be
included in the evaluation process if possible. It is important to note that
some depressed children attempt to compensate for their low self-esteem by
trying to please others and be accepted. Because in this effort they may excel
academically and behave well, their depression may go unnoticed. Adolescents
experience many developmental challenges as they strive to separate from their
parents, become autonomous and establish their own identities. In this process
they depend increasingly on their peer groups. This period of biopsychosocial
maturation creates the conditions for adolescents to experience a greater sense
of hopelessness and despair at a time when their ability to commit suicide is
greater than when they were younger. They also exhibit more anhedonia,
hypersomnia, weight change and substance abuse than younger children [4].
Thus depression in
children is characterized not only by unhappy and unresponsive facies but also
by other characteristic behavior which include anhedonia, social withdrawal,
decreased school work, poor appetite, sleep difficulty, excessive fatigue, hypo
activity, low self-esteem, worthlessness, guilt and self-destructive behavior
[2,6]. Before arriving to the diagnosis of depression, a child or teen that is
suspected to be depressed, must undergo a comprehensive medical evaluation to
rule out any underlying medical condition which could be manifesting as or
resulting in depression.
Oral manifestations of anxiety and depression
·
Poor oral hygiene
·
Increased caries activity
·
Gingival and periodontal diseases
·
Poor nutrition
·
Drug induced xerostomia
For mild to moderate
depression, CBT (Cognitive Behavioral Therapy) is the typical first-line
treatment of choice for children and teens. There can be exceptions to this,
depending on the specific clinical condition, age, and circumstance of the
child. For children younger than 10, other modalities of psychotherapy such as
play therapy, psychodynamic psychotherapy, and behavior therapy may be
utilized. Antidepressant medications may be considered first-line treatment for
moderate-to-severe depression or depression that has not responded to an
adequate trial of psychotherapy. Selective serotonin reuptake inhibitors are
the first-line antidepressant agents for children and adolescents diagnosed
with depression [6].
Children with anxiety disorders may have greater
dental anxiety. Consider use of behavior guidance techniques, i.e. voice
control, distraction, nitrous oxide [7]. Dental treatment for the symptoms can
be done in and calm and reassuring environment by dental care providers or use
of sedation or GA can be considered [5]. Some parents of children with anxiety
or depression may be reluctant to admit their child’s use of medication for an
anxiety disorder or depression. Be supportive and non-judgmental. Discuss
dental treatment with treating medical provider if needed. Mitral valves
prolapse is more common in children with anxiety disorders (8-33%). Consider
artificial salivary products for children with xerostomia. Dental erosion due
to gastroesophageal reflux can increase thermal sensitivity and in significant
cases cause pain. Educate patient on proper oral hygiene (brushing, flossing)
and nutrition [7].
Attention deficit
hyperactivity disorder (ADHD) is a common disorder in school-aged children
showing a prevalence of 5% and occurring two times more often in boys than
girls [8]. It is associated with significant impairment in social and academic
functioning. The classical triad of ADHD symptoms is characterized by lack of attention,
hyperactivity, and impulsiveness. There are three types of ADHD characterized
by symptoms: predominantly inattentive, predominantly hyperactive-impulsive,
and the combined form in which the two forms manifest themselves equally [8].
The etiology of ADHD remains unclear, although it is known to be
multifactorial, with genetic, biological, environmental, and psychosocial
factors [8]. There is no biological marker or laboratory test to confirm the
diagnosis.
Oral manifestations
·
Poor oral hygiene due to decreased attention span
·
Higher prevalence of gingival inflammation and dental caries
·
Bruxism
·
High risk for dental/oral trauma due to hyperactive and impulsive
behavior.
Psychostimulant
medication is the main pharmacological therapy for ADHD. The two stimulants
most prescribed are methylphenidate (Ritalin) and dexamphet-amine, which acts
by increasing dopamine and norepinephrine. Other medications sometimes used
include the antihypertensive clonidine, antidepressants and occasionally
neuroleptics. These medications have significant side effects, which must be
considered by the dental health team, such as xerostomia, loss of smell acuity,
sinusitis, dysgeusia, sialadenitis, stomatitis, gingivitis, discolored tongue,
bruxism, dysphagia, elevated blood pressure, and raised heart rate. Consider
use of nitrous oxide during treatment to manage behavior. Monitor caries
development, bruxism, and dental/oral trauma carefully. Recommend preventive
measures such as topical fluoride and sealants. Advise the use of fluoridated
toothpaste twice daily. Recommend rinsing the mouth with water after each dose,
especially after taking medications that cause xerostomia [9]. Review safety
issues appropriate to the age of the child, such as mouth guards to prevent
oral-facial trauma.
For the successful
management of these children, following can be considered.
·
Schedule appointments in the morning or at a time of day when child is
least fatigued, most attentive, and best able to remain seated in dental chair.
·
Give short, clear instructions directly to child. Give only one
instruction at a time.
·
Use Tell-Show-Do approach when introducing new procedures.
·
Tell child what is expected of him/her during the visit.
·
Consider small rewards for appropriate behavior (stickers, etc). Positive
reinforcement may be helpful in obtaining compliance.
·
Discuss appropriate behavioral interventions with parent.
·
Use of physical restraints can be considered when children are not
responding to other methods of behavior management.
It is the content of
consciousness or an idea or an impulse to act. It is an emotional state which
drives a feeling of compulsion which patient wants to get rid of or resists but
cannot do it. The characteristic feature is tendency to resist. It is
associated with distress and anxiety. The compulsion implies motor and vocal
actions taken to ward off obsessive thoughts. Common examples include checking,
cleaning excessive handwashing, showering or grooming. Other examples include
habitual nail biting, damage to cuticles and nails, paronychia and secondary
bacterial infections. OCD patients manifests Chronic multiple motor tics which
may present as involuntary blinking of eyes or spasmodic grimaces of facial
muscles.
Oral manifestations seen in OCD patients are
·
dental trauma involving injuries to enamel, gingiva and tooth abrasions
.
·
In rare occasions, extraction of tooth and bone injuries can be seen.
·
There is extensive teeth attrition which cannot be easily restored.
·
Habitual nail biting can cause self-inflicted gingival injuries and
dental problems, TMJ dysfunctions and osteomyelitis.
Treatment involves
psychiatric consultation and Behavioral therapy. Care must be taken of side
effects and drug interactions on oral health. Recall after every three months
is necessary to check oral health deterioration. If deterioration is seen it
indicates reoccurrence of OCD and should be discussed with psychiatrist to
evaluate needs of patient [10]. Dental restorations should be done for
maintaining normal eating function and preventing malnutrition.
It is a neuropsychiatric
disorder inherited genetically. It is seen in both sexes but more in boys. It
starts at an age of 5 to 10 years. 1 in 162 children have TS which is either
diagnosed or undiagnosed. In US, 1 in 360 children, 6 to 17 years of age have
been diagnosed of Tourette’s disorder.
The main symptom of
Tourette’s disorder is TICS. They are sudden twitches, movements or sounds that
people do repeatedly and cannot stop from doing it. For example, blinking eyes
over and over, making grunting sounds etc. There are two types of tics, Motor
tics and Vocal tics. A motor tic involves body movements like shrugging
shoulders or jerking an arm. Vocal tics involve making sounds like humming,
yelling a word or phrase, clearing the throat, etc. It usually starts as a
motor tics involving the head or neck area. It gets worse during stress or
excitement and reduces as the child calms down. Tics usually decrease during
adolescence and early adulthood and sometimes might disappear completely.
Tourette’s disorder has
been found in close association with another additional mental disorder like
ADHD or OCD [2].
The oral symptoms include
·
injury to the tongue, gingiva, and mucosa of the mouth during motor
tics.
·
Repeated injuries might cause severe ulcers with burning sensation. This
might cause difficulty in swallowing and eating.
·
Motor tics in oral region, which can cause pain or injuries, include
licking of the mouth or cheek, biting the lip or cheek, bruxism, and picking of
the oral tissue using the fingernail
·
Nutritional deficiencies might follow due to improper intake of food.
·
Use of proper orthodontic devices can prevent injury to the tongue and
other tissues [11]
·
Unconscious clenching or grinding of teeth is also seen. This might lead
to TMJ disorders [12]
There are no specific
diagnostic test or treatment plan available for TS. Treatment involves managing
tics so they do not cause hindrances in daily life. These include behavioral
psychotherapy and cognitive behavioral therapy, medications that block dopamine
in the brain and more intrusive surgical interventions involving deep brain
stimulation. However, the efficacy of these treatments can vary. As an
alternative treatment option, researchers at Osaka University have developed a
custom-made oral splint. These are typically used for unconscious teeth
clenching and grinding, and for temporomandibular disorders such as
misalignment of the teeth or jaw. The oral splint improved motor and vocal tics
in 10 children out of 14 in a study by Jumpei Murakami. The results were long
lasting and further research is being conducted in studying the effectiveness
of the splint in treatment of TS [12].
Mental health is the
most neglected aspect, especially in children. Every dental provider would at
some time have a patient with mental illness. Thus, having sound knowledge of
various mental illnesses and their effects on oral health could be a successful
key in early detection, management, and treatment of these patients. Dental,
mental, and physical health are not separate entities. Correlating these and
learning to treat the whole person expands and elevates the practice of dental
hygiene. The improved oral health adds to physical comfort, makes patients
socially acceptable which significantly impact quality of life.