Ogni antibiotico è efficace in relazione a un determinato gruppo di microrganismi
comprare ciprofloxacina online in italiain caso di infezioni oculari vengono scelte gocce ed unguenti.
Mental illness
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
CLINICAL CONCERNS IN DENTAL CARE FOR
PERSONS WITH MENTAL ILLNESS
Purpose of this Module
The information presented in this module is intended to provide the institutional dental staff with a compre-
hensive discussion of oral health care for persons with mental illness in institutional settings as well as thechallenges faced by the dental profession treating these persons in outpatient settings.
After reviewing this module, the participant will be able to:
1. Describe five psychiatric disorders commonly encountered in mental health facilities.
2. Discuss the oral manifestations commonly occurring in these five disorders.
3. Identify the drugs commonly used to treat these disorders.
4. Describe potential side effects and significant interactions encountered with psychotropic medicines and
drugs used in dentistry.
5. Discuss barriers to dental care and general concerns in the provision of dental care in mental health
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
CLINICAL CONCERNS IN DENTAL CARE FOR
PERSONS WITH MENTAL ILLNESS
population.1 Whereas it is estimated that one out of
A comprehensive discussion of oral health care for
every six persons (17%) in the general population
persons with mental illness (MI) in an institutional
suffers from some form of diagnosable mental disor-
setting is somewhat challenging due to the variability
der, ranging from a mild neurosis to a more serious
of populations served by mental health (MH) facili-
disorder such as schizophrenia.2 Mental retardation is
ties. In contrast, facilities that serve the mentally
a permanent condition even though the effects of this
retarded (MR) population are almost universally in-
cognitive deficit may be ameliorated
volved with persons with severe and profound mental
by special training programs and care. Mental illness,
retardation. These persons often have severe physical
on the other hand, may be sporadic in nature; for
and medical conditions especially cerebral palsy and
example, it is not uncommon for many persons to seek
seizure disorders and accompanying behavioral prob-
professional care for clinical depression once or twice
lems which frequently require physical restraint and
in their lifetime yet function adequately the remainder
often conscious sedation for the provision of dental
of their life without professional therapy or medica-
care. One type of mental health facility, for example,
may be in an urban environment and primarily serve
The advent of psychotropic medications available
persons with acute psychiatric disorders on a rela-
to treat persons with mental illness drastically changed
tively short term basis with an average length of stay
the MH institutional environment in the past several
of 3 to 6 months. Another MH facility may be a large
decades. With these
medications and other supportive
facility in a rural environment primarily serving per-
therapies, most persons with mental illness can live
sons with chronic psychiatric disorders that are rela-
within the community setting. The institution primar-
tively refractory to psychotherapy or pharmaceutical
ily serves those MI clients with chronic refractive
management. Yet another MH facility may serve
disorders (such as severe and chronic schizophrenia or
primarily elderly persons with dementia, including
dementia) and those persons temporarily institutional-
Alzheimer's disorder, and may closely resemble a
ized due to maladaptive behaviors associated with
community nursing home. Most of these facilities
exacerbations of mental illness (such as severe aggres-
also serve the person with alcohol abuse or other
sive behaviors associated with acute psychosis).
substance abuse (SA) problems and often encounter
Although there are certain skills and knowledge re-
clients with dual diagnoses (e.g. MI/MR or MI/SA).
quired by the general dentist in private practice to
Many facilities may serve all of these populations. In
properly treat the MI population compared with the
addition, they may be combined with a mental retarda-
general population, the dental implications involved
tion unit, may serve MR outpatients and occasionally
with treating the institutionalized MI population pres-
may serve MH clients from the community. There-
ent challenges of far greater magnitude.
fore, the challenges faced by the dental staff in a MHfacility may be more variable although not necessarilymore difficult than those faced by the staff in MR
AND IMPLICATIONS OF
The term "mental illness" generally refers to a
person who cannot perform major activities of daily
living due to a psychiatric or emotional disorder. This is in contrast to a person with mental retardation
Note: Much of the descriptive material in this
who has similar dysfunctions due to a cognitive or
section was excerpted, with permission, from
Patients
intellectual deficit. These two disorders, however, are
with Physical and Mental Disabilities: Oral Health
not mutually exclusive. The prevalence of mental
Care Guidelines American Dental Association, May
retardation is often reported as 3% of the general
1991. Copies of this manual may be obtained by
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
writing the ADA Council on Community Health,
guilt. The person may have difficulty with memory,
Hospital, and Institutional and Medical Affairs, 211
concentration and be easily distracted and indecisive.
East Chicago Avenue, Chicago, Illinois, 60611
Thoughts of death or suicide are common. Delusions
All dental staff in a MH facility should be familiar
or hallucinations are consistent with the person's
with and have access to the most current
Diagnostic
mood. These individuals can feel persecuted and hear
and Statistical Manual of Mental Disorders (DSM-
voices detailing their shortcomings. When an individ-
IV).4 This is the latest revision (1995) of this manual
ual is in the depth of depression, there is a significant
which was developed to standardize diagnosis of
impairment in personal hygiene and an almost total
psychiatric illness through use of specific criteria for
absence of oral hygiene. Common dental manifesta-
each diagnosis. The manual utilizes five axes to for-
tions of major depression are:
mulate the diagnosis of psychiatric patients. Use of
1. poor oral hygiene
the multiaxial classification system ensures that all
2. rampant dental decay
aspects of the illness and influences on it are consid-
3. advanced generalized periodontal disease
ered. No attempt will be made to discuss the
4. multiple missing teeth
multiaxial evaluation here, but the dental staff in a
5. ill fitting dental prostheses
MH facility should review and be familiar with the
6. various oral-facial pain syndromes
general concepts in the manual.
No attempt has been made to fully discuss the
8. poor nutrition, and poor diet
following syndromes but will concentrate on a briefdescription of the dental implications of these condi-
Major depression is usually treated with medica-
tions. The dental staff should consult appropriate
tions, psychotherapy, diet, exercise, correction of
psychiatric texts for more complete syndrome descrip-
sleep disturbances, and occasionally may be treated
tions and review the cited bibliographic references for
with electroconvulsive therapy (ECT). The most
further information on dental care of persons with
common antidepressant medications prescribed are:
these disorders. Although some information on vari-
a)Selective Serotonin Reuptake Inhibitors (SSRI's),
ous medications used to treat these disorders is pre-
b)Tricyclic antidepressants and combinations, and c)
sented here and in the following section, more com-
MAO (Monoamine Oxidase) inhibitors.
plete information on the side effects of major psycho-
Dental treatment involves addressing the problem
tropic drugs and the undesirable interactions of these
of poor oral hygiene and resultant decay and periodon-
drugs with drugs commonly prescribed by dentists
tal disease. Motivating the patient to improve oral
may be found in other sources.
hygiene procedures is often difficult. The issue of drymouth (xerostomia) associated with antidepressant
O
Major Depression5-9
medications must also be addressed. Xerostomia has
Major depression is an affective disorder (outward
been observed in 14% of those persons taking Prozac
manifestation of a person's feelings, tone or mood)
and in 45% of those taking Tricyclic antidepressant.9
characterized by a prolonged depressed disturbance of
Many of these individuals consume large amounts of
mood which significantly affects the person's life. It is
cariogenic fluids, candy and chewing gum in an effort
estimated that severe depression affects approx-
to combat this symptom. The prescription of artificial
imately 6% of the population and that nearly 3% of
saliva substitutes is often indicated.
the population requires at least one hospitalization for
Local anesthetics with epinephrine may be used
depression. Depression is a factor in more than
with prudence with patients taking tricyclic medica-
30,000 suicides in the USA annually. This syndrome
tions but is contraindicated with those taking MAO
is one of the most widespread of all life threatening
inhibitors. However, the use of local anesthetics with
disorders. There is a loss of interest or pleasure in all
Neo-Cobefrin or Levophed is contraindicated with
or nearly all daily activities and pastimes. The distur-
patients receiving tricyclic medications. The use of
bance is significant, persistent and may be associated
meperidine (Demerol) is absolutely contraindicated
with loss of appetite, loss of weight, sleep disturb-
with patients taking MAO inhibitors. The use of
ances (usually insomnia) and decreased energy. The
dental sedatives should be judiciously for those taking
individual will appear sad (frequently fearful) and
express feelings of worthlessness, hopelessness and
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
The dentist may be requested to fabricate a mouth
episodes. With increasing age the interval between
guard for patients scheduled for ECT. For these pa-
episodes becomes shorter and the length of each epi-
tients it is also important for loose teeth, gross calcu-
sode increases. Untreated persons have more depres-
lus and loose fixed or removable prostheses to be
sive episodes than manic episodes. One study11 of 40
addressed prior to ECT to prevent possible aspiration,
subjects showed that at time of admission, 37 were in
and to document existing condition if liability issues
the depressive stage and 3 in the manic stage of the
illness. All 40 subjects had a history of previouspsychiatric hospitalization. The onset of the disease
O
Bipolar Disorder10-13
after age 21 occurred in 83% of these subjects. Heavy
Bipolar disorder, also called manic-depressive
smoking (one or more packs a day) was reported in
disorder, is an affective disorder in which the patient
93%, alcohol dependence in 38% and a history of
suffers from alternating, prolonged episodes of ex-
cocaine abuse in 20% of those subjects was reported.
treme elation and depression. This condition affects
The dental manifestations of the manic stage of
approximately 1% of the general population and there
this disorder may include abraded oral mucosa and/or
is a strong familial pattern to this disease.
cervical tooth abrasion secondary to the over-vigorous
Periods of mania are generally characterized by
use of toothbrushes or dental floss. The dental mani-
hyperactivity which involves excessive participation
festations of the depressive stage of this disorder are
in multiple activities (e.g. sexual, occupational, politi-
identical to those described under major depression
cal, religious). There is an intrusive and demanding
nature to these activities which goes unrecognized by
Anti-seizure medications, lithium carbonate and
the patient. Pressured speech is common. It is loud,
neuroleptics (phenothiazine family of drugs) are effec-
rapid and difficult to interrupt. Speech is theatrical
tive in treating the manic phase of this disorder. Lith-
and dramatic, and there are abrupt changes in topic
ium carbonate is usually effective in 70% of patients
(flights of fancies or ideas).
within 3 weeks. The depressive episodes are treated
Persons with bipolar disorder are easily distracted
with the temporary administration of antidepressant
and some display grandiose delusions in which they
medications described above for major depression.
claim a special relationship to God or some well
Persons on lithium therapy may complain of a gener-
known figure from the political or entertainment
alized stomatitis and concurrent xerostomia; although
world. They may go for days with little or no sleep
hypersalivation has been reported. Xerostomia was
and yet not appear tired. Lability of mood with rapid
reported in 73% of the subjects in the above study11
shifts to anger or depression is common.
after lithium treatment had begun.
During periods of depression, there is a loss of
Major adverse interactions between lithium and
interest in almost all daily activities. This period is
medications commonly used in dentistry are rare.
identical to the individual with major depression de-
However, the use of nonsteroidal anti-inflammatory
scribed above. Impairment in social and occupational
drugs (NSAID) may decrease the renal clearance of
functioning occurs during both phases of the disorder
lithium and allow a buildup of toxic levels. Short
with marital instability, alienation from family, and
term use of NSAIDs may not pose a problem. Benzo-
the inability to hold a job being common. These indi-
diazepines should be used with caution due to the
viduals have a need for protection from the conse-
potential for CNS depression. Major problems with
quences of poor judgement, hyperactivity and the
antidepressant drugs used for the depressive stage of
predilection to violent acting out. The most common
this disorder have previously been discussed.
complications of a manic episode are substance abuseand the consequences of actions resulting from im-
paired judgement, such as financial losses and illegal
Schizophrenia is a psychotic disorder characterized
activities. The most common complication of an
by varying degrees of personality disorganization
episode of depression is suicide.
which lessens an individual's ability to effectively
The periodicity of the disease is variable with
work and communicate with others. Approximately
episodes lasting approximately 3 months and possible
1-2% of the general population will need hospitaliza-
reoccurrences every 3-9 years. The manic episodes
tion because of this disorder at one time in their lives.
tend to be of shorter duration than the depressive
It is characterized by impairment of routine daily
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
functions such as work, social relations and self care,
Benadryl. Long term effects of a similar nature,
that lasts for at least 6 continuous months. A predom-
termed tardive dyskinesia, also include trismus, swal-
inant characteristic is the disturbance of several psy-
lowing dysfunctions, tongue protrusion, or Parkinso-
chological processes. Thoughts are disrupted by
nian-like movements which include continuous facial
bizarre (absurd and imagined) delusions (a firm, fixed
movement, particularly of the lips and jaws which may
idea without rational explanation). Persecutory delu-
include lip chewing, tongue wiping, smacking move-
sions (being spied on) and delusions of reference
ments and general skeletal movements. Tardive dys-
(giving unusual negative significance to other people
kinesia is associated with long term antipsychotic
or events, such as thinking that a television program is
therapy, especially the phenothiazines, and can often
specifically directed at them), are common. These
be controlled by Cogentin and Artane. Akathisia may
individuals can believe that their thoughts are being
develop in these patients and is manifested by rest-
broadcast and that their feelings and impulses are
lessness, inability to sit still and a tendency to move
under the control of others. Their ideas may rapidly
their body and legs during treatment. These people
shift between unrelated subjects, frequently making
have a desire to get up and move about during their
their speech incoherent. They can have major distur-
dental appointment.
bances in perception by having hallucinations (a false
Dental sedative medications should be used with
sensory perception - the hearing of voices that make
caution to prevent a synergistic reaction with the neu-
insulting statements - in the absence of an actual ex-
roleptic agents resulting in excessive respiratory de-
ternal stimulus). They often present a flattened or
pression. Local anesthesia with epinephrine causes no
blunted affect (absence of demonstrable emotions
adverse effects in normotensive patients.
along with a monotonous voice and expressionlessface). They may question their own identity and lack
the drive to follow a course of action through to its
Dementias have been variably classified as medical
logical conclusion. There may be a reduction in spon-
(neurologic) and/or psychiatric disorders and include
taneous movements, catatonic rigidity or bizarre man-
Alzheimer's disease. Dementia is a loss of intellectual
nerisms such as grimacing, hyperactivity and pacing.
function sufficiently severe to interfere with social or
Because these individuals are frequently confused,
occupational abilities. This loss involves memory,
depressed, withdrawn, or anxious they often neglect or
judgement, abstract thought, and a variety of higher
refuse dental care. Family disassociation, marginal
cortical functions. Individuals 65 years of age and
social and economic adjustment and legal problems
older are most susceptible to organic brain syndromes.
exacerbate this issue. This dental neglect and often
The prevalence of dementia increases in individuals
poor oral hygiene, in conjunction with the xerostomia
over age 65, from approximately 2-3% of those aged
caused by some antipsychotic medications, lead to
65 through 79 to more than 20% for those 80 years of
increased incidence of dental decay and periodontal
age and older. Patients with dementia, regardless of
disease. Patients with paranoid schizophrenia may be
the pathophysiology of their condition, are character-
very suspicious and should be approached, verbally
ized by progressively poor short term memory result-
and physically, very slowly and in a nonthreatening
ing in a potential for agitation, disorientation and
manner. There should be no sudden movements. The
inappropriate behavior in unfamiliar settings. More
patient should be warned of things to expect and
advanced states of the disease are typically marked by
should be shown what is going to be done at each next
incontinence, increasing loss of abilities to perform
self care, limb contracture and eventually a vegetative
Schizophrenia is usually treated with antipsychotic
state and then death. In most advanced dementias,
or neuroleptic drugs which include the phenothiazines
apraxia (a disorder of voluntary movements) and
and other antipsychotic agents which generally have
memory loss are profound. Patients become incapable
some beneficial effect on the patient's mood and
of recognizing and making proper use of objects nor-
thought processes. These neuroleptic agents can
mally utilized in daily living (including toothbrushes,
cause short term extrapyramidal symptoms (EPS)
etc.). Many of these patients are prescribed neurolep-
which include generalized agitation or jitteriness,
tic medications to control behaviors which often cause
spasms of neck muscles (torticollis) and oculogyric
xerostomia previously discussed.
crises which can usually be controlled by use of IM
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
Patients with dementia often manifest the follow-
a single dose of most drugs will produce a peak blood
ing dental problems:
level twice as high and a half-life twice as long as in a
1. maxillofacial injuries (usually due to falls)
younger patient.
2. traumatic oral ulcerations
In addressing the maladaptive behaviors presented
3. poor oral hygiene
in the dental environment by patients with dementia,
4. extensive coronal and root cavities
many of the management and communication tech-
5. increased periodontal disease
niques used with the mentally retarded population are
6. numerous missing or severely broken teeth
appropriate (See Module 2). These would include:
7. attrition, abrasion and migration of residual
communicating acceptance and reassurance, increased
utilization of non verbal communication (e.g. smiling,
8. salivary gland dysfunction
making eye contact, gently touching the patient), more
9. severe atrophy of residual alveolar ridges
repetition of instructions, avoidance of abstract terms,
10. nonfunctional dental prostheses
and use of nouns rather than pronouns, short words
and sentences, and simple verbal communication.
O
Alcohol and Other Substance
Dental treatment should be completed as early as
possible in progressive dementias (e.g. Alzheimer's
Whether coupled with a psychiatric disorder
Disease), since inability to cooperate due to behavioral
(MI/SA dual diagnosis) or presented as a primary
dysfunction increases as the dementia progresses. If
disability, the dental treatment of persons with alco-
long term care is anticipated (e.g. permanent facility
holism and other substance abuse (SA) problems
admissions), full mouth diagnostic radiographs should
presents a great challenge to the dental staff in MH
be taken, if at all possible, for future reference, when
facilities. The prevalence of alcoholism alone has
the progressive dementia renders radiographs impossi-
been estimated at 28-50% in psychiatric hospitals.38
ble. As with most psychiatric disorders, consultation
The person with alcoholism is also more likely to
with the patient's treatment team (including physician)
abuse or be dependent on other (illicit) drugs such as
will provide valuable information on present self-help
heroin and cocaine. The definition of alcohol abuse,
and behavioral limitations as well as some estimate as
alcohol dependence, other substance abuse and de-
to the rate of loss of these functions in the future. The
pendence can be found in thediagnostic manuals
problem of drug-induced xerostomia has previously
and/or reference texts.
been discussed. The problem with candidiasis is
The dental implications of alcoholism include:
experienced by 5-20% of these patients on antipsy-
1. poor oral hygiene
chotic medications. Current methods of treatment are
2. dental neglect
appropriate for this population, for example the use of
3. dental attrition (bruxism)
chlorhexidine rinses and denture scrubs are helpful but
4. xerostomia (atrophy of salivary glands)
they must be tailored to the patient's ability to use
5. higher incidence of oral cancer (heavy
them properly. Many patients can not rinse solution
for 30 seconds and will swallow everything put in
6. candidiasis (poor nutrition)
their mouth. In addressing the problem of dental
7. impaired wound healing (liver damage)
decay (especially root caries), more frequent recalls
8. orofacial trauma
for prophylaxes and fluoride applications may be the
9. bleeding tendency (liver damage)
only option. Adverse interactions between drugsprescribed by the dentist and medically prescribed
Dental management of these patients involves
neuroleptic drugs has been previously mentioned.
addressing the above issues. Since there is an in-
Since liver and kidney functions are often drastically
creased risk of intraoperative or postoperative
diminished in old age, the prescription of any medica-
bleeding, a bleeding profile (CBC, PT, PTT and
tion should be made with caution. Particularly long
bleeding time) is often indicated prior to oral surgery.
acting drugs and long term use of nonsteroidal anti-
The tendency toward a prolonged healing process and
inflammatory agents need to be used with caution. A
increased risk of postoperative infection may prompt
good rule of thumb is to remember that in the elderly,
greater use of antibiotics post surgically. Perioral
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
damage, including fractured mandibles, is usually
primary agents (e.g., ibuprofen) fail. The amount of
treated by an oral surgeon through referral. However,
medication dispensed should be enough to last only
the dentist should be aware that a significant number
through the worst of the patient's pain, usually no
of these patients have developed osteomyelitis of the
more than 48 hours, and if possible, be dispensed by
mandible following a compound fracture. The higher
someone other than the patient to avoid self-medica-
risk of oral cancer requires careful screening at the
tion. Any medication for merely anticipated pain
time of initial dental examination. Alcoholic patients
absolutely should be avoided. To reduce the need for
may have an altered response to many medications.
postoperative analgesics, a long lasting local anes-
As they develop a tolerance to ethanol, they also de-
thetic such as bupivacaine (Marcaine) may be em-
velop a tolerance for sedative drugs, and often require
ployed. Recovering alcoholics on Antabuse therapy
higher than usual doses to achieve the desired degree
should avoid all oral or topical alcohol based products
of sedation. All drugs metabolized by the liver should
such as mouth washes. Non-alcohol containing mouth
be given with caution. These include: lidocaine
washes are commercially available.
(Xylocaine), mepivacaine (Carbocaine), ampicillin,aspirin, acetaminophen (Tylenol), codeine, diazepam,
COMMON PSYCHOTROPIC
and barbiturates. It has been recommended that theester class of local anesthetics (Ravocaine) be used for
MEDICATIONS AND MAJOR SIDE
patients with alcoholic cirrhosis.28 It has been reported
that for patients with long histories of chronic alcohol-ism, a significant increase in the quantity of local
Note: No attempt has been made to be all inclu-
anesthetic is needed to control pain.30
sive of psychiatric medications or their range of poten-
The dental implications and management of the
tial side effects. It is very difficult to keep an up to
patient who abuses or is dependent on substances
date listing of psychotropic drugs as new drugs are
other than alcohol is similar for the alcoholic patient.
constanly being added. Please review current refer-
Patients who use, abuse or are dependent on illicit
ences regarding recent psychotrophic medications.
drugs, often intravenously administered, are clearly at
The following information, some of which has
higher risk for HBV and HIV infection. The manage-
previously been mentioned under the specific mental
ment of these conditions including infection control
illness, is intended to serve as general information.
concerns, are not included here. Cardiac irritability
References listed at the end of this module will pro-
and hypotension are major complications of cocaine
vide additional information.
use (especially with crack' cocaine). The use of alocal anesthetic with epinephrine is strongly contrain-
dicated with anyone who has used cocaine within the
A number of antidepressant agents are used
last 48 hours. Hyperactivity and hypersensitivity to
today, falling into three categories:
local anesthetics has been reported with this group.30
1. Selective Serotonin Reuptake Inhibitors
The dental management of the recovered or recov-
ering chemically dependent patient (both alcoholism
a. Adapin (doxepin)
and drug addiction) presents additional challenges.
b. Anafranil (clomipramine)
Care should be taken in prescribing drugs with mood-
c. Asendin (amoxapine)
altering potential. This includes sedative medications
d. Elavil (amitriptyline)
(including Nitrous Oxide/Oxygen analgesia) and
e. Etrafon (perphenazine and
potentially addictive analgesics which would include
virtually all pain medications except nonsteroidal anti-
f. Limbitrol (chlordiazepoxide and
inflammatory drugs such as aspirin, ibuprofen and
diflunisal. If the prescribing dentist has any concerns
g. Ludiomil (maprotiline)
regarding the use of analgesia for substance
h. Norpramin (desipramine)
abuse/dependence patients, he/she should contact the
i. Pamelor (nortriptyline)
attending physician. In cases involving major severe
j. Sinequan (doxepin)
periodontal or oral surgery, narcotic agents should be
k. Surmontil (trimipramine maleate)
prescribed with extreme caution and only after the
l. Tofranil (imipramine)
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
m. Triavil (perphenazine and amitriptyline
n. Vivactil (protriptyline)
Antimanic agents administered today in the treat-
ment of the manic stage of bipolar disorders include:
2. Tricyclic Antidepressants and Combina-
1. Lithonate (lithium carbonate)
2. Certain neuroleptics
a. Prozac (fluoxetine)
3. Anti-seizure medications (Depakote and
b. Zoloft (sertraline)
c. Paxil (paroxetine)d. Desyrel (trazodone)
The neuroleptics will be discussed under the sec-
e. Effexor (venlafaxine)
tion on antipsychotic agents where the reader will find
f. Serzone (nefazodone)
a number of precautions. Adverse reactions betweenlithium carbonate and medications commonly used in
3.
Monoamine Oxidase Inhibitors (MAO)
dentistry are limited to nonsteroidal anti-inflammatory
a. Marplan (isocarboxazid)
drugs (NSAID's) as previously discussed. The risk of
b. Nardil (phenelzine sulfate)
elevated serum lithium levels with patients receiving
c. Parnate (tranylcypromine sulfate)
both lithium carbonate and NSAID drugs may beminimal for those receiving only short term regimens
Precautions for patients being treated with these
of NSAIDs for dental pain. However, a medical con-
medications must be taken since antidepressant agents
sultation, with the patient's physician, may be consid-
can cause adverse reactions of concern to dentists.
ered prior to prescribing NSAIDs. Erthromyan can
These agents may affect the cardiovascular system
significantly raise the blood level of Tegretal. If this
causing hypotension, orthostatic hypotension, tachy-
combination is to be used, it should be discussed with
cardia, arrhythmias, myocardial infarction and conges-
the attending physician.
tive heart failure. Additionally, anticholinergic activ-ity may cause dry mouth.
Adverse reactions between antidepressant agents
Antipsychotic agents administered today in the
and drugs used in dentistry may produce significant
treatment of schizophrenia and other psychiatric disor-
interactions. Central nervous system depressant medi-
cations such as general anesthesia agents, sedativesand hypnotics, barbiturates, and narcotics can have a
Atypical Antipsychotics
potentiating interaction resulting in severe respiratory
A. Clozaric (clozapine)
depression. In fact, the use of Demerol is absolutely
B. Risperdal (resperidone)
contraindicated in patients taking MAO inhibitors.
C. Olanzipine (zyprexa)
The use of anticholinergic drugs such as atropine orscopolamine can cause an increase in intraocular pres-
Caution should be taken when using benzodrozepine
sure. Certain antihistamines such as phenylephrine
for sedation in patients taking clozeril. Discuss this
should not be used with MAO inhibitors. Local
combination with the attending physician.
anesthetics with epinephrine should be used withcaution in patients receiving MAO inhibitors. Should
Convetnional Neuroleptics
local anesthetics with epinephrine be used with pa-
1. Mellaril (thioridazine)
tients taking other types of antidepressants (other than
2. Prolixin (fluphenazine)
MAO inhibitors) the amount of local anesthesia
3. Stelazine (trifluoperazine)
should be limited to three carpules of 1:100,000 epi-
4. Thorazine (chlorpromazine)
nephrine and intravascular injections must be avoided.
5. Haldol (haloperidol)
Epinephrine in concentrated forms such as retraction
6. Loxitane (loxapine succinate)
cords should be avoided. Leuonordefrin would not be
7. Navane (thiothixene)
recommended for use in patients receiving tricyclicantidepressents.20
It may be helpful to note that agents 1-4 fall into
the phenothiazine type of antipsychotic agents. Inter-actions between antipsychotic medications and drugs
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
used in dentistry can produce adverse reactions. Ef-
cessfully compete for adequate resources (staff, space,
fects of these drugs which are significant to dental
and budget) required to meet the dental needs of the
management include:
1. Cardiovascular effects such as tachycardia,
Details of patient consent for treatment have been
changes in blood pressure, orthostatic hypo-
extensively covered in Modules 6 and 13. However, it
should be reemphasized that issues of patient consent
2. Hematopoietic effects such as decreased red
in MH facilities differ from those in MR facilities in
and white blood cells and platelets.
two major areas. First, the psychiatric client may be
3. Tardive dyskinesia
admitted (voluntarily or involuntarily) to a psychiatric
facility due to his/her inability to function within the
5. Extrapyramidal reactions
community, yet he/she may still retain competence insome areas of function, including the ability to compe-
These agents can interact with CNS depressant
tently accept or refuse dental care. Whereas a severely
medications causing severe respiratory depression.
retarded individual in a MR facility is seen as incom-
This can be dangerous, particularly in patients with
petent (either defacto, dejure or both) to make such
compromised respiratory function. If these drugs
decisions and consent is usually obtained from the
must be used, the dosage must be reduced and the
legal guardian. Clearly, a psychiatric patient may be
dentist might be wise to consult with the patient's
equally incompetent to make decisions about dental or
physicians. Atropine and scopolamine
medical care but the issue is not as obvious and
(anticholinergic agents) can cause an increase in intra-
straight forward as with the person with
ocular pressures. The use of local anesthetics with
severe/profound mental retardation. Another issue is
epinephrine should follow the same precautions as
the refusal of dental care by a patient with severe and
with the antidepressants, aspirate when injecting to
progressive dementia. The dentist can get a general
avoid intravascular injections and use no more than 3
feeling of what the patient might desire for dental
carpules of 1:100,000 epinephrine. Epinephrine in
treatment by discussing details with the family and
concentrated forms such as retraction cords should be
reviewing the type of dental care received in the past.
However, legally you are bound to informed consentfor treatment and whatever legal status the patient
GENERAL DENTAL CARE CONCERNS
presents with. If the patient has Alzheimer's diseaseand a guardian has not been appointed, their consent
IN A MENTAL HEALTH FACILITY 41-49
must be obtained from the patient after discussingtreatment options. Competency can be discussed with
The programmatic and administrative challenges
the psychiatrial or attending physician to see if they
expected by dental programs within these facilities
believe the patient can understand simple statements
will vary greatly with the size of the facility, the char-
regarding treatment. If the patient can not give con-
acteristics of the population(s) served, and budgetary
sent, only emergency treatment which threatens the
issues. The primary function of the facility is seen as
health of the patient can be rendered until a guardian
admitting a psychiatric patient (usually in acute cri-
is appointed.
sis), ameliorating their psychoses and returning these
The question as to the appropriate level of care
persons to the community as functioning individuals.
based upon the expected length of patient admission is
Medical concerns (including dental) that are not per-
a constant dilemma for the dental staff. Short term (4-
ceived as having a direct impact on the psychiatric
10 week) residents usually receive only emergency or
management of the patient are often seen as incidental
palliative care. For long term residents (2 years of
to the mission of the facility and unimportant. Often,
longer) comprehensive care, including prostheses, is
it is the dental staff that recognizes that dental pain
appropriate. Unfortunately, the expected length of
and discomfort often exacerbate the psychoses of
admission is not usually clear to the hospital staff.
these patients and that the dental neglect experienced
Observing the abrupt discharge of a patient in the
by so many of these clients prior to admission, con-
midst of restorative or prosthetic dental care or dis-
tributes to their depression, anxiety and negative self-
covering a long term resident neglected by having
image. Therefore, it is the dental staff who must
received only emergency care is clearly frustrating for
accept the role of advocate for these clients and suc-
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
the dental staff. For restorative treatment, an accept-
The maintenance of a positive, caring, nonthreatening,
able attitude may be that it is better to provide four
accepting and non-judgmental professional attitude
quadrants of restorative treatment to one patient than
with patients who are often anxious, fearful,
to provide one quadrant of treatment to four different
untrusting, agitated and occasionally combative, is
clients: At least one person will be restored to full
often difficult. The fact that most dental staff in men-
dental health with the former attitude.
tal health facilities do so with aplomb and consistent
The unanticipated discharge of a patient in the
commitment is admirable.
middle of prosthetic construction is particularly frus-trating for the dentist. Not only is a considerable
OUTPATIENT SERVICES FOR
amount of staff time wasted, but interim laboratorybills have been generated to no subsequent purpose.
MENTAL HEALTH CLIENTS50-53
One approach is to gain a commitment from the pa-tient's treatment planning team, prior to the initiation
Although few facilities presently offer outpatient
of prosthetic care, that in the event discharge occurs
dental services to persons with mental illness, there
prior to treatment completion that arrangements will
may be a greater demand for these services in the
be made by the community agencies to return the
future. There is a paucity of information to guide the
individual to the facility as an outpatient to complete
dental staff on this issue, but the following mono-
the prosthetic treatment and that these arrangements
graph presents a description of one institutional pro-
will be clearly stated in the patient's discharge plan.
gram providing these services50.
The delay of a person's discharge from a psychiatricfacility merely to complete dental treatment is usually
not an acceptable option.
There has been considerable media attention in
A converse dilemma for the dentist is the occa-
recent years on the plight of the homeless population
sional need for the dentist to convince a patient's
in the United States. Some of this population consists
treatment planning team that dentures for certain
of individuals with mental illness, many of whom have
psychiatric patients are not a possibility due to the
previously been provided dental care in an institu-
patients inability to tolerate the prosthesis. This is
tional setting. Estimates as high as 40% of the home-
particularly a problem in patients with behavioral
less population have a diagnosis of mental illness.51
problems common in dementia or with severe
Many of these individuals also have alcoholism and
dyskinesia due to psychotropic drug use. For exam-
substance abuse problems. In addition, there are an
ple, severe tardive dyskinesia almost always precludes
even greater number of previously institutionalized
the success of a complete denture.
mental health clients in supportive living arrange-
The material presented makes it clear that most
ments within the community who cannot afford pri-
patients in psychiatric facilities are prescribed a multi-
vate dental care and for whom dental services are not
tude of medications which may have a negative impact
provided by Medicaid or other public assistance ar-
on dental care and may produce serious and/or unde-
sirable interactions with drugs prescribed by the den-
There are numerous references outlining the spe-
tist. Although this training module and other litera-
cific dental needs of individuals with mental illness
ture references may prepare the dentist for possible
and substance abuse. Most of these sources emphasize
adverse events, a close working relationship with the
the problems of poor oral hygiene, undesirable side
facility's clinical pharmacist(s) is mandatory for
effects of psychotropic medications and the high de-
proper patient care. The pharmacy staff are not only
gree of dental neglect, including periodontal disease,
convenient in a MH facility but are almost always
seen in many of these individuals. Other references
cooperative and eager to work with the dentist in drug
provide excellent material on the dental management
choice, dose selection, or possible adverse action or
of persons with specific psychiatric disorders such as
drug interactions.
schizophrenia, clinical depression and bipolar disor-
Although the dentist should be familiar with the
ders as well as alcoholism and drug abuse.8-16 There is,
various aspects and manifestations of different psychi-
however, a paucity of information on the planning,
atric diagnoses, it is clear that the dentist and staff do
implementation, administration and evaluation of
not treat a diagnosis but provide care to an individual.
dental programs for community placed mental health
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
clients who cannot access traditional sources of care
part of dental staff accustomed to exclusively serving
due to their continued
the client with mental retardation.
The funding for both the MR and MH outpatient
The following is a description and discussion of
programs was provided though use of the institutional
one example of this type of program.
budget including payment of dental laboratory fees.
No fees were charged to the clients since inability to
pay for private services was part of the eligibility
In 1972 the Georgia Retardation Center, a residen-
tial facility for persons with mental retardation (MR),initiated outpatient dental services for similar individ-
#
Client Eligibility
uals who reside in the community. The number of
Since mental retardation is a permanent disability,
clients served rose over a 6-8 year period to approxi-
once eligibility for services based upon this disability
mately 1,600 individuals and has remained relatively
has been established it will not need verification on a
static for the past 14 years. The eligibility criteria
periodic basis. Mental illness, however, is often an
include the diagnosis of mental retardation and the
intermittent disability and verification is necessary
inability of the client to access services elsewhere,
periodically. In this program, application for services
either from private or other public resources.
for mentally retarded (MR) clients are accepted pri-
In 1985 this facility, renamed Brook Run in 1991,
marily from local MR agencies and occasionally di-
also initiated a limited outpatient program for commu-
rectly from parents living in the community. Although
nity based clients with mental illness. This program
there is some potential for abuse of eligibility require-
served a selected geographic area of the state and
ments for those parents directly requesting services, it
included 19 counties both urban and rural. The reason
is considered minimal. There have been no requests
for initiating this program was to serve as an example
for services from individuals with mental retardation
to other institutional programs and to act as a pilot
themselves. In contrast, since eligibility for mental
project to determine the advantages and difficulties of
health (MH) clients required more than a psychiatric
this type of service. Referrals were only accepted
diagnosis and unavailability of alternative resources,
from specified state and county supported Mental
referral through a Mental Health Center caseworker
Health (MH) centers within the selected geographic
was considered mandatory. This program did not
area and client eligibility included: 1) The individual
initially have a reverification process and some clients
is presently enrolled in the MH Center programs, (2)
continued to receive care who became ineligible for
no services are available from any alternative
geographic or other reasons. After three years, a form
resource, 3) the treatment is expected to make a sig-
was sent to all caseworkers for eligibility reverifica-
nificant contribution to the client's rehabilitation plan,
tion. This procedure resulted in approximately 20%
and 4) there is a reasonable expectation that the client
of the MH census being discharged. Some similar
will follow through with the planned treatment. Writ-
outpatient programs have indicated that eligibility is
ten verification of client eligibility was made by the
reverified on each visit or monthly. This appears
referring caseworker during the referral process. The
burdensome to the dental staff. Regardless of the
number of MH outpatients served rose over a two year
verification procedure or schedule, abuses can occur.
period to approximately 250 and has since remained
One client confided that her counseling services at the
relatively stable by periodic freezes on acceptance of
Mental Health Center were requested solely to become
new clients, together with discharges of clients who do
eligible for dental services. Other clients, especially
not continue to meet the eligibility criteria.
those that are highly manipulative, can sway a case-worker into referral for dental services even though
other resources are available for that client. Clients
Over several years, there emerged some significant
who are articulate, stylishly dressed and transport
differences in providing outpatient dental services to
themselves in a current model automobile create
individuals with mental illness compared to those with
doubts about their eligibility on the part of the dental
mental retardation. Some of these perceptions of
differences, however, may be the result of bias on the
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
dental services differed for the MH client. For many
A major problem that surfaced was the difficulty in
clients there is a greater need for both restorative and
establishing contact with the typically overloaded
prosthetic services due to many factors including
referring caseworker. Treatment plans and expecta-
cariogenic medications, poor oral hygiene and pro-
tions involve dentist/caseworker agreements as well as
longed periods of dental neglect. The need for pros-
dentist/patient agreements. The referring caseworker
thetic services has a special budgetary impact due to
may understand and agree upon the necessity of dental
the need for dental laboratory services. After three
care for the client but have little understanding at the
years, cast restorations were eliminated from the array
time of referral what will be involved in meeting the
of services provided MH clients and composite and
client's dental needs. For the first several years of this
stainless steel crowns were substituted where full
program, the dental staff provided all services indi-
coverage was indicated. Cast restorations are still
cated for the patient with little feedback to the case-
provided MR clients since the requirement for these
worker. In order to acquire caseworker input and/or
restorations is low in this population due to poor oral
approval of the planned treatment, a consultation form
hygiene, lack of adequate cooperation and other fac-
was completed with a complete treatment plan and
tors. Similarly, cast removable partial dentures were
forwarded to the caseworker following the initial
eliminated and all-acrylic partial dentures or all-
dental appointment. This procedure has proven bur-
acrylic with wrought wire clasps were substituted for
densome and unworkable. No efficient alternative has
the MH client. These dentures require a lower labora-
been developed at present to assure client, caseworker
tory cost and are easier to repair. Removable partial
and dental staff are in agreement to the limitation of
dentures are provided only when a major esthetic or
the treatment planned and the responsibilities of the
functional advantage is gained. Complete dentures
continue to be a significant need for the MH popula-
The need for dentist/mental health client and den-
tion and constitute a major portion of program and
tist/caseworker communication and agreement on
budget time.
treatment goals is altogether different than when serv-
The demand for services by the MH client does not
ing individuals with mental retardation (MR). Ser-
necessarily coincide with the dental needs identified
vices for the MR client involve only parent/guardian
by the dentist. There is an exaggerated focus by many
or caseworker communication and agreements on
of these individuals on esthetic concerns. Demands
treatment planned. If a MR client were able to negoti-
for fixed partial dentures, cast restorations for esthetic
ate treatment considerations, he/she would most likely
purposes only and even removable partial dentures to
be served in other settings; most are resistive to care
replace a single missing posterior tooth are common.
and many require dental restraints and/or sedation to
Often these demands take total priority in the hierar-
provide needed services. Although, the community
chy of the patient's concerns even when there are other
based MH client is not capable of providing for many
significant restorative and periodontal needs present.
of his/her critical daily living needs, he/she is almost
This is in contrast to MR clients who make few de-
always capable of communicating his/her desires for
mands for care, although occasionally a parent will
dental services, even when these desires are unrealistic
have unrealistic expectations, especially concerning
for a public dental program to provide. This need to
prosthetic replacement of missing teeth.
constantly debate provider capabilities with the pa-
A particularly frustrating situation for both the
tient with mental illness is a significant source of
dentist and the client occurs when the patient has a
frustration for the dental staff.
preexisting extensive and expensive prosthesis en-dangered by caries or other pathology and that cannot
#
Limitations to Care
be replaced due to budgetary constraints of the outpa-
The resources available for this program, as with
tient program.
most public programs, are limited and cannot meet thetotal demand for care. When this pilot program was
#
Compliance
begun, the array of dental services provided was the
The percentage of broken and cancelled dental
same as for MR clients which included all basic dental
appointments is very high with this population, espe-
services except orthodontic treatment. It quickly
cially if the client is responsible for his/her own trans-
became apparent that the needs and demands for
portation. A recent small survey by a similar program
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
revealed that 40% of the MH clients failed to com-
3. The issue of follow up preventive services must be
plete treatment due to broken and cancelled appoint-
addressed. If routine prophylaxes and periodic
56 This is less of a problem if the client is trans-
dental examinations following the completion of
ported by the caseworker. The MH client often does
dental treatment are contemplated, the total num-
not have available an extensive family support system
ber of clients who could be served would need to
common to many MR clients. Conversely, since many
be reduced. The issue of follow-up care also in-
of these individuals do provide their own transporta-
volves broken or lost prostheses and broken resto-
tion, they often appear at irregular, inappropriate
rations. One suggestion is to discharge all clients
times and frequently ask for unavailable or inappro-
once the initial and agreed upon treatment plan has
priate services, sometimes couched in terms of a need
been completed. At this point the caseworker can
for emergency care. Also, there is less tolerance on
recommend that the client continue to be provided
the part of the dental staff in dealing with the MH
follow up preventive and treatment services or
client's lack of compliance in oral hygiene and care of
substitute another client whose rehabilitation needs
prostheses and other issues. This intolerance is gener-
are more pressing.
ated when, unlike many MR clients, these clients
4. The limitations of available dental treatment must
appear so capable in many ways.
be clearly stated at the initiation of the program. Ifresources including supporting laboratory budgets,
IMPLICATIONS FOR FUTURE
are limited, it may be appropriate to eliminate the
provision of cast restorations, cast removable
The following are issues that are vital components
partial dentures, endodontics for posterior teeth,
to a successful outpatient program for mental health
extraction of non-symptomatic impacted teeth,
clients regardless of whether the program is institution
extensive periodontal surgery or other procedures.
based, community hospital based or based within a
Any expectation of provision of emergency ser-
city or county public health dental program.
vices during hours when the clinic is not in opera-
1. Since the number of clients needing care usually
tion should be clearly addressed.
exceeds the dental resources available, a method of
5. A method of verifying the treatment plan and ob-
allocating these resources is important. If referrals
taining the caseworker's agreement should be de-
are only accepted from designated sources, such as
veloped. This is particularly important in
community mental health centers, an allocation of
instances where the client's expectations exceed
a certain number of clients from each referring
the dental program's ability to provide services. It
agency based upon total number of clients able to
is important that on the application for services,
be served may be an equitable system.
the caseworker's name is printed or typed and a
2. The conditions of eligibility must be clearly out-
current telephone number provided.
lined by the dental program and a written verifica-
6. A method of limiting the number of broken ap-
tion from the referring caseworker that these re-
pointments must be developed. The inability to
quirements have been met must be obtained prior
keep arranged dental appointments is but one dys-
to the first dental appointment. A system of rever-
functional behavior exhibited by many of these
ification of eligibility must be agreed upon prior to
clients. It is emotionally wearing on the dental
initiating care. This process should not be burden-
staff to be judgmental in the face of the many real
some for the caseworker or dental staff. An annual
and often dramatic difficulties in daily living ar-
reverification appears reasonable. The eligibility
rangements experienced by these individuals. Yet
criteria listed in the above program description
multiple broken appointments have a significant
have proven of value. However, eligibility criteria
negative impact on the availability of care. A limit
should be developed to meet the limitations for the
of two consecutive broken appointments before a
specific dental care resource.
client is discharged may be a reasonable one.
If lack of alternative resources is part of the
7. Some agreement should be made for instances
eligibility criteria, the provision of a referral
where client eligibility changes prior to completion
directory listing private and public resources
of treatment. A client may move to a non-served
should be provided to all referring agencies and
geographic area or temporarily cease to attend the
mental health center program.
SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9
8. Client transportation is an important aspect of the
fourth edition, Amer. Psychi. Assoc. 1994,
problem of broken dental appointments. It is quite
Washington, D.C.
helpful if the caseworker or designee transports theclient to the dental program. This is particularly
5. Friedlander, A.H., et al. The dental management
important when the client is experiencing an exac-
of depressed patients.
Spec. Care Dent. 7(2),
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Mar/Apr 1987, 65-6
9. The arrangements for funding and client fees for
services is outside of the scope of this discussion
6. Friedlander, A.H., et al. Dental management of
since each would be individual to a specific dental
the child and adolescent with major depression.
resource. However, whatever fee arrangement is
Jr. Dent. Child. 60(2), Mar/Apr 1993, 125-31.
expected should be clearly communicated at the
initiation of treatment. This is very importantwhen dental laboratory fees are involved or when a
7. Friedlander, A.H., et al. Dental management of
consultant fee is necessary. An example of the
the patient with major depression.
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8. Brown, R.S. Dental management of the patient
It is likely that the demand for dental services for
with major depression (letter/comment).
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the community placed individual with mental illness
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will dramatically increase over the next decade. Many
state and local agencies have been reluctant to initiateprograms to meet the dental needs of these clients due
9. Wynn, R.L. Antidepressant medications.
Gen.
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Friedlander, A.H., et al. The dental manage-
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provided, successful efforts can be made to alleviate
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