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Mental illnessSOUTHERN 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), erbation of dysfunctional behavior.
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. Oral Surg., latter is when a surgical procedure unexpectedly Oral Med., Oral Pathol., 71(5), May 1991, 573- exceeds the capabilities of a general dentist.
8. Brown, R.S. Dental management of the patient It is likely that the demand for dental services for with major depression (letter/comment). Oral the community placed individual with mental illness Surg., Oral Med., Oral Pathol., 72(4), Oct.
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. to the many difficulties in providing other services to Dent. 40(3), May/June 1992, 192-7. (16 Ref) this population. Indeed, these difficulties are real andoften monumental. Yet, with sound planning, clear Friedlander, A.H., et al. The dental manage- communication, and carefully drawn limits to services ment of patients with bipolar disorder. Oral provided, successful efforts can be made to alleviate Surg., Oral Med., Oral Pathol., 61(6) June the dramatic dental neglect experienced by so many of 1986, 579-81.
Friedlander, A.H., Dental conditions in pa-tients with bipolar disorder on long-term lith- ium maintenance therapy. Spec. Care Dent.
Sept/Oct 1990, 148-51.
1. Robinson & Robinson, The Mentally Retarded Friedlander, A.H., et al. Dental management Child, 1976, McGraw Hill, New York. York.
considerations in children with obsessive-compulsive disorder. ASDC Jr. Dent. Child 2. Quock, R.M. Clinical complications in the psy- (58)3, May/June 1991, 217-22. chiatric dental patient. Compend. Contin. Educ.
Dent. 6(5), May 1985, 333-4, 338-40, 342.
Friedlander, A.H., et al. Dental managementof the patient with obsessive-compulsive dis- 3. Burtner, A.P. & Dicks, J.L. Providing oral health order. Spec. Care Dent. 11(6), Nov/Dec individuals with severe disabilities re- 1991, 238-42.
siding in the community: alternative care deliv-ery systems. Spec. Care in Dent. 14, 1994, 188- Friedlander, A.H., et al. The dental manage- ment of patients with schizophrenia. Spec.
Care Dent. 1986 Sept/Oct 6(5), 217-8.
4. American Psychiatric Association, Diagnostic and statistical manual of mental disorders, SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9 Friedlander, A.H., et al. Oral health care for Langer, A. Chemopsychotherapy and its role the patient with schizophrenia Spec. Care in prosthodontic failures in elderly patients. Dent. 11(5), Sept/Oct 1991,179-83. Jr Prosth. Dent 52(1) Jul. 1984, 14-9.
Clark, D. B. Dental care for the psychiatric Jacobsen, S., et al. Oral candidiasis S fre- patient: chronic schizophrenia Jr. Can. Dent. quency, treatment and relapse tendency in a Assoc. 58(11), Nov. 1992, 912-6, 919-20. group of psychiatric inpatients. Acta. Odontol. Scand. 37(6) 1979, 353-61.
Paterson, A.J., et al. Self-inflicted mutilation Friedlander, A.H., et al. Alcoholism and den- of the dentition in a schizophrenic patient, tal management. Oral Surg. Oral Med. Oral Brit. Dent. Jr. 173(9), Nov. 21, 1992, 314-6.
Path. 63(1), Jan 1987, 42-6. (28 Ref) Davidson, M., et al. Dental treatment respon- Aston, R. Treating pain and anxiety in the sibility for the delusional patient. Gen. Dent. reformed substance abuser. Jr. Mich. Dent. Mar/Apr 1990, 143-6.
Assoc. 69(6), June 1987, 279-80.
Chiodo, G.T., et al. Tardive dyskinesia. Gen Williamson, R., et al. Drug-dependent, Dent. 38(4), Jul/Aug 1990, 289-91.
alcohol-dependent, and mental patients: clini-cal study of oral surgery procedures. Jr. Becker, D.E. The Autonomic Nervous Sys- Amer. Dent. Assoc. 86, Feb. 1973, 416-9.
tem and related Drugs in Dental Practice. PartII: Adrenergic Agonists and Antagonists. King, W.H., et al. Dental problems of alco- Compendium. 9(10), Nov/Dec, 1988, 772- holic and nonalcoholic psychiatric patients.
Q.J. Stud. Alcohol. 34, Dec. 1973, 1208-11.
Shuman, S.K., Ethics and the patient with de- Ratcliff, J.S., et al. Dental management of the mentia. Jr. Amer. Dent. Assoc. 119(6), Dec., recovered chemically dependent patient. Jr. 1989, 747-8.
Amer. Dent. Assoc. 114-(5), May 1987, 601-3.
Chiodo, G.T., et al. Diminished autonomy: Can a person with dementia consent to dental Laskin, D.M. Looking out for the cocaine treatment? Gen Dent 40(5), Sept/Oct 1992, abuser (editorial), Jr. Oral Maxillofac. Surg. 51(2), Feb. 1993, 111.
Boccia, A. Alzheimer's disease and the dental Quartey, J.B., Dentistry and the chemically patient. Recognizing and dealing with demen- dependent patient. Dentistry 12(4), Dec.
tia. Ont. Dent. 69(3), Apr. 1992, 16-8.
Hiltbrunner, A.V. Argument against provid- Cook, H. et al. Management of the oral sur- ing dental care for the severely cognitively gery patient addicted to Heroin. Jr. Oral. impaired patient. Gerodontics 4(4), Aug.
Max. Surg. 47(3), Mar. 1989, 281-5. (17 Ref) 1988, 168-9.
Miers, D. R., et al. Chemical dependency. Volicer, L. Pharmacologic management of Guidelines for the treatment of recovering behavioral problems in adult dental patients chemically dependent dental patients. Jr. with severe cognitive impairment. Amer. Coll. Dent. 56(1) Spring 1989, 4, 6-8.
Gerodontics, 4(4), Aug. 1988, 160-1. SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS — Self-Study Course Module 9 Friedlander, A.H. et al. Dental management McCall, W.V. Exacerbation of mental illness of the cocaine addict. Oral Surg, Oral Med., by dental disease. Psychosomatics 32(1), Oral Path. 65(1), Jan. 1988, 45-8. (20 Ref) Winter 1991, 114-5.
Friedlander, A.H. et al. Dental management Ter Horst. Dental care in psychiatric hospitals of the geriatric alcoholic patient. Gerodontics in the Netherlands. Spec. Care Dent. 12(2), 4(1), Feb. 1988, 23-7.
Mar/Apr 1992, 63-6.
Isaacs, S. O. et al. "Crack" (an extra potent Huckelberry, J.W., et al. Oral orthopedics form of cocaine) abuse: a problem of the and its relationship to mental health disorders.
eighties. Oral Surg. Oral Med. Oral Path. Jr. Indiana State Dent. Assoc. 50, April 63(1), January 1987, 12-6.
Gage, T.W. & Pickett, F.A. Dental Drug Ref- Dicks, J. L., Outpatient Dental Services for erence, Mosby-Year Book, Inc., 1994.
individuals with mental illness: A programevaluation. Submitted for publication March Horden, A. Dental dilemma, can psychiatry help? Aust. Dent. Jr. 22(4), Aug. 1977, 295- Mental disorder among homeless persons in the United States: an overview of recent em-pirical literature. Robertson M.J. Administra- Millspaw, R.R. Nitrous oxide and the psychi- tion in Mental Health 14:14-27, Fall 1986.
atric patient: report of a case. J Nat Analg Soc5(2), Apr/Jun 1976, 18-9.
Mills, S.H. Deinstitutionalization and clinicaldental practice. Gen. Dent. 37(2) Mar/Apr.
Dilling, L. F. When the patient's problem is 1989, 138-40.
all in his head. Dent. Manag 15(8), Aug.
1975, 17-8, 20, 24-5.
Dillenberg, J., et al. Dentistry and the men-tally ill on Cape Cod. Jr. Mass. Dent. Soc. Wishner, J.L. The role of the dentist in the 29(1), Winter 1980, 33-5.
mental hospital. N.Y. Dent. Jr. 36, Oct. 1970,478.
Markette, R.L. et al. Dentistry and the men-tally ill. Jr. Acad. Gen. Dent. 23(3):28-30, Pinkham, J.R. Practical considerations for March-April 1975.
dental assessment and treatment of mentallyand emotionally ill patients. Jr. Dent. Handi. Stiefel, D.J., et al. A comparison of the oral 4(2), Summer 1979, 50-6.
health of persons with and without chronicmental illness in community settings. Spec. Barnes, G.P. et al. Dental treatment needs Care Dent. 10(1), Jan/Feb 1990, 6-12.
among hospitalized adult mental patients. Spec. Care Dent. 8(4), Jul-Aug, 1988, 173-7.
Markette, R.L. Unpublished Survey I. Atlanta,Georgia 1983.
Wrist Watch Blood Pressure MonitorInstruction manual Tensiomètre Automatique PoignetMode d'emploi Tensiómetro de MuñecaManual de instrucciones Monitor de Pressão Arterial de PulsoManual de instruções Wrist Watch Blood Pressure MonitorInstruction manual Table of contents 1.1. Features of the WW 1YB-31.2. Important information about self-measurement Important information on the subject of blood-pressure and its measurement