Disease/Medical Condition

BIPOLAR DISORDER Date of Publication: June 20, 2019

(also known as “manic-depressive illness” and “bipolar illness”; includes “bipolar disorder I”, “bipolar disorder II”, and “cyclothymic disorder” [also known as “cyclothymia”])

Note: Unless otherwise specified, this fact sheet primarily addresses the manic aspect of bipolar disorder. Depression is addressed in more detail in a separate fact sheet.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated? No, unless the patient/ client displays manic, catatonic, or psychotic behaviour that poses a risk to himself/herself or the dental hygienist during procedures (e.g., pronounced distractibility, psychomotor agitation, or disorganized behaviour).

■ Is medical consult advised? — No, if bipolar disorder has been previously diagnosed and is well controlled. — Yes, if bipolar disorder is newly suspected (e.g., manic behaviour) or poor control of previously diagnosed bipolar disorder is suspected (e.g., manic or depressive signs/symptoms). Immediate referral is indicated if suicidality is suspected.

Is the initiation of invasive dental hygiene procedures contra-indicated?** No, unless the patient/ client displays manic, catatonic, or psychotic signs/symptoms that pose a risk to himself/herself or the dental hygienist during procedures (e.g., pronounced distractibility, psychomotor agitation, or disorganized behaviour).

■ Is medical consult advised? ...... See above. ■ Is medical clearance required? ...... No, unless severe leukopenia (i.e., reduced white blood cell count, and hence immunosuppression) or thrombocytopenia (i.e., reduced platelet count, and hence increased bleeding risk) is suspected with mood-stabilizing medication (particularly carbamazepine and valproic acid) or antipsychotic1 medication (particularly quetiapine, clozapine, and the phenothiazine class) use. [This would be a rare situation in the dental hygiene office setting.] ■ Is antibiotic prophylaxis required? ...... No (in the absence of immunosuppression). ■ Is postponing treatment advised? ...... No, unless: – medical clearance is pending regarding possible immunosuppression or thrombocytopenia associated with mood-stabilizer; – the patient/client exhibits manic, catatonic, or psychotic signs/symptoms that may pose risk during, or cause inability to perform, procedures, in which case medical treatment is first needed; or – severe signs/symptoms of depression exist (in which case attainment of better depression control may be indicated before attempting elective dental hygiene procedures).

Oral management implications

■ In a severe manic or depressive episode of bipolar disorder, catatonic signs/symptoms (e.g., extreme physical agitation or refusal/inability to open mouth or speak) augur against performance of dental hygiene procedures. ■ Stimuli (e.g., noise and light) should be reduced to the extent possible to avoid overstimulation, a susceptibility in bipolar disorder. ■ In patients/clients with mania or hypomania, conversations should be kept brief and focused only on immediate matters. ■ The dental hygienist should be alert for signs/symptoms of leukopenia (e.g., recurrent and persistent oral infections/lesions and sore throat) and/or thrombocytopenia (e.g., petechiae) in patients/clients taking carbamazepine, valproic acid, or certain antipsychotic drugs.

1 Phenothiazines (e.g., chlorpromazine, thioridazine, fluphenazine, prochlorperazine, perphenazine, and trifluoperazine), which are an older category of antipsychotic medications, may be used in the management of bipolar disorder when the patient/client fails to respond to, or can no longer take, lithium. However, their use has largely been supplanted in recent years by generally safer, better tolerated, and more efficacious “atypical” antipsychotics, including quetiapine, risperidone, olanzapine, clozapine, and aripiprazole.

cont’d on next page...

Disease/Medical Condition

BIPOLAR DISORDER

Oral management implications (cont’d)

■ The dental hygienist should be alert for signs/symptoms of alcohol and illicit drug abuse, including missing teeth. Referral for addiction counselling or to a physician may be indicated. ■ The dental hygienist should be alert for signs/symptoms of poor nutrition. Referral to a dietitian or physician may be indicated. ■ For medication-induced Parkinsonian muscle side effects, a bite block and low volume suction during dental hygiene procedures may be helpful. ■ Management of iatrogenic xerostomia is important. ■ To reduce patient/client-induced gingival trauma and tooth abrasion, use of a soft toothbrush should be encouraged. Grinding of teeth can be managed with a bruxism appliance. ■ Nonsteroidal anti-inflammatory drugs (NSAIDs), erythromycin, tetracycline, and metronidazole increase serum lithium levels, potentially leading to toxicity. Thus, they should be used cautiously, if at all, in patients/clients taking lithium. ■ Because antipsychotic drugs may potentiate the sedative action of tranquilizer and opioid medications, if the latter are used their dosage may need to be reduced to avoid serious respiratory suppression.

Oral manifestations

■ Dental abrasion can result from overzealous brushing and flossing during the manic phase of bipolar disorder, as can gingival and mucosal lacerations. ■ Xerostomia is a side effect of some antidepressants (e.g., tricyclics), mood stabilizers (including lithium and lamotrigine), and some antipsychotics (e.g., quetiapine). Heavy tobacco and caffeine use further exacerbate dry mouth and related oral manifestations. ■ Stomatitis and dysgeusia (often “metallic” in nature) can result from lithium use. ■ Damage to tooth enamel and mouth ulcers are side effects of lamotrigine. ■ Mastication muscle spasms, pseudoparkinsonianism (resulting in a mask-like face and drooling), lip smacking, and tongue protrusion can result from antipsychotic use (in the atypical class, most notably risperidone). ■ Erosion of tooth structure, rapid decay, periodontal disease and other suspicious lesions may result from illicit drug abuse. ■ Gingivitis, breakdown of mucosal tissue, and periodontal destruction may result from inadequate nutrition associated with either manic or depressive episodes.

Related signs and symptoms

■ Bipolar disorder is characterized by unusual shifts in mood, energy, activity levels, and the ability to carry over everyday tasks. Its cause is linked to various factors, including genetic predisposition and alterations in brain chemistry2 and structure3. Like most mood disorders, bipolar disorder tends to be cyclic.

2 Reduced brain concentrations of the neurotransmitters serotonin and norepinephrine have been linked to depression, and increased levels are thought to contribute to mania, although the definitive cause(s) of bipolar disorder is unknown. 3 Treatment of bipolar disorder includes pharmacotherapy, psychotherapy (including cognitive behavioural therapy), and electroconvulsive therapy (ECT). Drug treatment of bipolar disorder has two goals: firstly, rapid control of symptoms in acute episodes of mania and depression, and, secondly, prevention of future episodes and reduction in frequency and severity. The mainstays of drug therapy are mood- stabilizing drugs (some of which are also anticonvulsants), which include lithium carbonate (most commonly used), valproic acid, divalproex, carbamazepine, and lamotrigine. As well, atypical antipsychotics are increasingly being used in conjunction with mood-stabilizers or as antidepressants in bipolar disorder. Mixed manic and depressive episodes are challenging to manage; often, the manic behaviour needs to be first stabilized with a mood-stabilizer or atypical antipsychotic (e.g., olanzapine), and then depression is addressed with an antidepressant drug (e.g., fluoxetine).

cont’d on next page... 2

Disease/Medical Condition

BIPOLAR DISORDER

Related signs and symptoms

■ Bipolar disorder affects about 1% to 2% of the adult Canadian population. Most persons are in their teens or early 20s when the symptoms of bipolar disorder first appear; onset is rare over 50 years of age. ■ Bipolar disorder occurs with equal frequency in both sexes. However, men tend to have a greater number of manic episodes than women who, in turn, have a greater number of depressive episodes. On average, 10 episodes are experienced in a lifetime, and untreated episodes may last months. ■ Patients/clients with bipolar disorder have at least one episode of mania, hypomania (mild mania), or hypomanic symptoms. Most persons who become manic or hypomanic will eventually experience depression, and many patients/clients initially experience depression followed by mania or hypomania. ■ Types of bipolar disorder include: – bipolar I disorder, which consists of manic episodes that last at least 7 days (or which are so severe that the person requires immediate hospital care), usually interspersed with depressive episodes lasting at least 2 weeks (i.e., major depression), or a mixture of manic and depressive signs/symptoms that occur at the same time. – bipolar II disorder, which consists of recurrences of hypomania (but not full-blown mania as above) and depressive episodes; and – cyclothymic disorder, which manifests as recurrent brief episodes of hypomanic signs/symptoms and numerous periods of mild depressive signs/symptoms ongoing for at least 2 years in adults (1 year in children and adolescents). ■ Between episodes, many patients/clients are free of mood changes, but some persons may have lingering symptoms. ■ A manic episode includes a distinct period in which the affected person’s mood is elevated and expansive (i.e., euphoric, “high”, or “up”) or irritable, angry, disruptive, and aggressive. Associated symptoms of mania include inflated self-esteem, grandiosity, decreased need for sleep, energized behaviour, increased appetite, increased libido, flight of ideas (racing thoughts), excessive speech, distractibility, psychomotor agitation, poor judgment4, social loss of inhibition, and reckless pursuit of pleasurable activities. ■ In mania, speech is often rapid, loud, and difficult to interpret. Behaviour may be demanding and intrusive. Style of dress may be strange and colourful. ■ Psychosis5 can occur in a patient/client with severe episodes of mania or depression. ■ Catatonic signs/symptoms (i.e., movement problems) occur in up to about 25% of patients/clients with pure or mixed manic episodes or with depression. These motor problems vary and may include extreme physical agitation, slowness, or odd postures or movements. ■ Patients/clients with bipolar disorder are at elevated risk of migraine headaches, obesity, diabetes mellitus, and other physical illnesses. Anxiety, attention-deficit hyperactivity disorder (ADHD), binge eating disorder, alcohol and drug abuse, personality disorder, and obsessive-compulsive disorder are common co-morbidities. Long-term lithium use is associated with hypothyroidism, nontoxic goitre6, cardiac arrhythmias, and diabetes insipidus7. ■ Some patients/clients experience only one manic or hypomanic episode of bipolar disorder, although the condition is usually considered a lifelong illness; many take a mood stabilizer (usually lithium) on an ongoing basis and experience less frequent or severe episodes and function well; and some continue to have frequent and/or severe episodes with ongoing disability despite treatment. ■ Bipolar disorder can lead to death. Suicide risk is significant.

4 Legal and financial problems may result. 5 Psychotic symptoms include hallucinations (hearing, seeing, tasting, smelling, or feeling something that is not really present) and delusions (false beliefs with no basis in reality). 6 Goitre is generalized enlargement of the thyroid gland. 7 Diabetes insipidus is characterized by polyuria (large amounts of urine) and polydipsia (increased thirst), which, in the case of long-term lithium use, is thought to be caused by drug effects on the kidneys.

cont’d on next page... 3

Disease/Medical Condition

BIPOLAR DISORDER

References and sources of more detailed information

■ College of Dental Hygienists of Ontario http://www.cdho.org/Advisories/CDHO_Advisory_Bipolar_Disorder.pdf ■ Rosmus L, Cobban SJ. Bipolar Affective Disorder and the Dental Hygienist. CJDH. 2007;41(2):72-83. https://www.cdha.ca/pdfs/Profession/Journal/v41n2.pdf ■ Kisely S. No Mental Health without Oral Health. Can J Psychiatry. 2016;61(5):277-282. https://www.ncbi.nlm.nih.gov/pubmed/27254802 ■ Clark DB. Dental Care for the Patient with Bipolar Disorder. JCDA. 2003;69(1):20-24. https://www.cda-adc.ca/jadc/vol-69/issue-1/20.pdf ■ Centre for Addiction and Mental Health http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/bipolar_disorder/ Pages/Bipolar-Disorder.aspx ■ Canadian Mental Health Association https://cmha.ca/mental-health/understanding-mental-illness/bipolar-disorder/ ■ National Institute of Mental Health, National Institutes of Health https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml ■ University of Washington School of Dentistry https://dental.washington.edu/wp-content/media/sp_need_pdfs/Depression-Adult.pdf ■ WebMD https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-forms https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-treatments-bipolar-mania#5 ■ National Institute for Health and Care Excellence https://www.nice.org.uk/guidance/cg185 (Bipolar Disorder) ■ Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St. Louis: Elsevier Mosby; 2013.

*Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc. **Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.

Date: November 30, 2017