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Pearls

Poor in the mentally ill: Be aware of the problem, and intervene

Snehal Kadia, MD, Radhika Bawa, MD, Hema Shah, MD, Puneet Narang, MD, and Steven Lippmann, MD

Drs. Kadia, Bawa, and Shah oor oral health is common among sumption also can cause thrombocytope- are Observer Physicians and mentally ill people and is related to nia and bleeding, which can complicate Dr. Lippmann is Professor, University of Louisville School of Medicine, inadequate nutrition, poor self-care, dental procedures. P Louisville, Kentucky. Dr. Narang substance abuse, and medication side is Staff Psychiatrist, Regions effects.1 Poor oral hygiene is a significant Smoking cigarettes increases the inci- Hospital, St. Paul, Minnesota. problem because it results in dental pathol- dence of , especially Disclosures ogy that has an adverse influence on the necrotizing and candidiasis.7 The authors report no financial relationships with any company whose whole body. Ninety percent of patients with schizo- products are mentioned in this article Compared with the general population, phrenia smoke—compared with up to 70% or with manufacturers of competing products. mentally ill patients are 3 times more likely of patients with other psychiatric disor- to have their teeth removed.2 In a survey of ders, and 19% of the general population.7,8 mentally ill adults, 92% were found to have Physiologic aspects of schizophrenia rein- —of which 23% were untreated force the smoking habit.7 and 40% smoked tobacco.3 Approximately 9% have periodontal disease, which most Somatic ailments. Psychiatric disorders often occurs in those who smoke cigarettes.4 are strongly associated with diabetes, obe- sity, hypertension, stroke, heart disease, Lifestyle contributors and arthritis, all of which contribute to oral Drug abuse facilitates dental diseases, pathology. Older age, greater dysfunction, as evidenced by the high rate of caries longer duration of illness, and smoking are among users.5 The predictors of adverse dental outcomes. drug induces , encouraging users to drink sweetened beverages; this, Anxiety, depression, stress—all of these combined with limited oral care, results in these disorders increase the circulating level profound dental decay (“meth mouth”). of cortisol, thus raising the risk that peri- Oral users often exhibit dental ero- odontal disease will progress.9 Periodontitis sions or abrasions, gingival lacerations or increases the risk of stroke and heart attack necrosis, and mucosal lesions. Smoking by accelerating atherosclerotic plaque for- Cannabis is associated with an increased mation.10 Depression, anxiety, and substance rate of gingivitis, alveolar bone loss, leu- abuse can lead to temporomandibular disor- koplakia, and oral papilloma or other can- ders that cause pain and restrict jaw move- cers.5 Heroin users are at increased risk ment.11 Stressed patients may experience of tooth decay, periodontal disease, and muscle tension and , which can lead oral infection.5 to discomfort. Alcohol consumption increases the risk of . Long-term alcohol use sup- Eating disorders. Patients who induce presses bone marrow function, causing vomiting may exhibit enamel erosions leukopenia and resulting in immunosup- (especially on the anterior maxillary teeth), pression and an increased incidence of increased tooth hypersensitivity, decay, Current Psychiatry dental infections.6 Excessive alcohol con- and wear on dental restorative work. Vol. 13, No. 7 47 continued Pearls

Atypical odontalgia, characterized by patient’s dentist and primary care physi- chronic, burning pain in teeth and , cian, facilitates health care and works to is associated with depression and anxiety.11 offer the patient access to global medical Misdiagnosis can result in extractions or services. procedures without an appropriate indica- tion and failure to alleviate the pain. References 1. Mental Illness Fellowship of Australia Inc. Overview of the oral health of people affected by mental illness. http:// www.wfmh.com/links/external-contacts/mental-illness- Medication side effects. Xerostomia can fellowship-of-australia. Accessed June 18, 2014. increase the risk for caries, periodontal 2. Kisely S, Quek LH, Pais J, et al. Advanced dental disease in people with severe mental illness: systematic review and disease, and oral infections such as candi- meta-analysis. Br J Psychiatry. 2011;199(3):187-193. 9 diasis, , , and . 3. Dental caries (tooth decay) in adults (age 20 to 64). National Extrapyramidal side effects (tardive dyski- Institute of Dental and Craniofacial Research. http:// www.nidcr.nih.gov/DataStatistics/FindDataByTopic/ nesia, dystonia) may cause tooth damage DentalCaries/DentalCariesAdults20to64.htm. Updated January 6, 2014. Accessed June 18, 2014. and make managing dentures difficult.6 Smoking 4. Peridontal disease in adults (age 20 to 64). National Institute of Dental and Craniofacial Research. http://www.nidcr. Cannabis is nih.gov/DataStatistics/FindDataByTopic/GumDisease/ What to tell patients, and what PeriodontaldiseaseAdults20to64.htm. Updated January 6, associated with you can do for them 2014. Accessed June 18, 2014. 5. Maloney WJ. The significance of illicit drug use to dental an increased Encourage your patients to reduce their practice. http://www.webmedcentral.com/wmcpdf/ sugar intake, brush and floss regularly, and Article_WMC00455.pdf. Published July 28, 2010. Accessed rate of mouth June 18, 2014. work to stop smoking or ingesting sub- diseases, bone 6. Oral health care for people with mental problems: guidelines stances of abuse. Teach appropriate hygiene and recommendations. British Society for Disability and loss, and cancers Oral Health. http://www.bsdh.org.uk/guidelines/ and nutrition, which reduces the risk of den- mental.pdf. Updated January 2000. Accessed June 18, 2014. tal caries, infection, and related problems. 7. Lohr JB, Flynn K. Smoking and schizophrenia. Schizophr Res. 1992;8(2):93-102. Recommend periodic oral health screening 8. Centers for Disease Control and Prevention (CDC). Vital and how to secure such dental care. signs: current cigarette smoking among adults aged ≥18 years–United States, 2005-2010. MMWR Morb Mortal Wkly From your position of familiarity with Rep. 2011;60(35):1207-1212. patients’ psychopharmacotherapy, make 9. Yoffee L. The link between oral health and medical illness. http://www.everydayhealth.com/dental-health/oral- an effort to personalize and adjust their conditions/oral-health-and-other-diseases.aspx. Updated regimens when dental disease is present November 9, 2012. Accessed June 18, 2014. 10. Demmer RT, Desvarieux M. Periodontal infections and to address concerns about oral health that cardiovascular disease: the heart of the matter. J Am Dent can be caused by medication side effects. Assoc. 2006;137(suppl 2):14S-20S; quiz 38S. A multidisciplinary approach with 11. Mental illness and the dental patient. American Dental Hygienists’ Association. http://www.adha.org/ce- patient advocacy, involving you and the course-10. Accessed June 18, 2014.

Current Psychiatry 48 July 2014