Mental Health and Its

II Relevance to Dentistry
Ranganath D. Rattehalli, Sandip Deshpande

The first half of 20th century saw the accidental discov-

Introduction ery of malaria being therapeutic for psychosis in tertiary
syphilis. This led to the dangerous practice of injecting
milk to induce fever. Inducing seizures by Insulin Coma
This chapter aims at equipping the reader with skills to
Therapy or injecting Camphor Oil which was considered a
recognize the commonly seen mental illness. In addition
successful treatment for Schizophrenia then is largely
to giving a broad overview of mental illness and present
‘barbaric’ this day in age. The biggest breakthrough for
day psychiatric practice we intend to focus on the inter-
Psychiatry came in the 1950s with the discovery of
face between ‘dentistry’ and ‘psychiatry’. We will also give
Chlorpromazine and the First World Congress of Psychiatry
you a broad overview of the treatment options available in
at Paris. Since then Psychiatry has probably seen the inven-
psychiatry. In addition to making you confident in recog-
tion of numerous new medications, perhaps much more
nizing the mental illness in order to refer them to psychia-
than most other branch of medicine. However present day
try, this chapter will give you confidence in dealing with
psychiatry has outgrown the medical model and has incor-
the mentally ill when they develop dental problems.
porated a ‘bio-psycho-social’ model both for understand-
ing and treating mental illness.
History of Psychiatry

Concepts of Mental Illness and

Tracing the timeline backwards, in 10,000BC there was no
difference between medicine, magic and religion. Looking
at the history of medicine it may seem that Psychiatry as
a specialty is relatively new. However the history of Psy-
chiatry dates back to more than 2,000 years when medi-
cine itself had its birth as ‘Science’ in ancient Greece. In
the ancient world, Psychiatric illness was believed to come
from the Gods and the curse of the devils. People have
always been fascinated and puzzled, not being able to
understand ‘insanity’. It is interesting to note the varying
perceptions of the public, media, arts and the society at
large towards the ‘mad’ among us.
For centuries mental health problems and their treat-
ments has been the realm of not only Physicians but also
a range of other professionals including ‘faith healers’. Till
the 18th century the mentally ill were secluded in ‘institu-
tions’ and ‘asylums’. In the next stage, mid 18th century,
some Physicians in England and France started recogniz-
ing themselves as having a special interest in dealing with
mental health. But still there was no treatment available
and the mentally ill were ‘chained’ at large. It was Philippe
Pinel, a French Physician who in 1793 started an initiative
towards the ‘moral treatment’ of the mentally ill and ‘lib-
erated’ the insane from their chains.
Its Classification
Similar to using the word ‘illness’ loosely in everyday speech,
the word ‘mental illness’ is used with little precision in
psychiatric practice, and often synonymously with ‘mental
disorder’. In this context, ‘mental’ and ‘psychiatric’ are also
used interchangeably. A very diverse discussion of the con-
cepts of mental illness can be found in the works of Lazare
(Lazare, 1973), Kendell (Kendell, 1975), Hafner (Hafner, 1987)
and Clare (Clare, 1997). It is probably beyond the scope of
this chapter to go into the depths of these concepts.
Definitions of Mental Illness
There have been numerous attempts to define mental illness
but none have been satisfactory and uniformly accepted.
One of the common approaches is to examine the concept
of illness as in general medicine and to identify any analo-
gies with mental illness. In general medicine there are five
types of definitions:
❑ Absence of health
❑ Disease is what doctor treats

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❑ Biological disadvantage
❑ Pathological process
❑ Presence of suffering.
Efforts to classify psychiatric disorders have been tried my
many over the years. Since there are no definite diagnostic
tests such as radiograph for fracture or blood test for malaria
we need different tools to provide a conceptual framework
to the psychiatric illness. Having a classificatory system
helps us to communicate with other professionals and to
decide on treatment and prognosis.
Current Psychiatric Classifications
The two major classificatory systems in use for the psychi-
atric disorders are the ICD 10 and the DSM IV and it is
important to have the basic understanding of both.
International classification of diseases (ICD-10),
Chapter V
The International Classification of Diseases (ICD) is pro-
duced by the World Health Organization (WHO) as an aid
to the collection of international statistics about disease.
The system is revised every few years and the current edi-
tion is the tenth (ICD-10). It has 22 chapters in it and the
fifth chapter is devoted to psychiatry.
Main categories of ICD 10 Chapter V (F)
F00–09 Organic including symptomatic mental disorders
F10–F19 Mental and behavioral disorders due to
psychoactive substance use
F20–F29 Schizophrenia, schizotypal and delusional disorders
F30–F39 Mood (affective) disorders
F40–F49 Neurotic, stress related and somatoform disorders
F50–F59 Behavioral syndromes associated with
psychological disturbances and physical factors
F60–F69 Disorders of adult personality and behavior
F70–F79 Mental retardation
F80–F89 Disorders of psychological development
F90–F99 Behavioral and emotional disorders with onset
usually occurring in childhood or adolescence
Diagnostic and statistical manual (DSM)
The DSM is produced by the American Psychiatric Associ-
ation (APA). The first edition, DSM-I was published in 1952
as an alternative to the widely criticized ICD-6. It seems
that the DSM-I was strongly influenced by the views of
Adolf Meyer and Karl Menninger. Its simple glossary reflects
the acceptance of the then prevalent psychoanalytic ideas
in the USA. The current version is the DSM IV and it has
five axes as shown in the table below.
Appendix2.indd e25
Appendix II – Mental Health and Its Relevance to Dentistry
The five axes of DSM IV
Axis I Clinical syndrome and ‘conditions not attributable
to mental disorder that are the focus of attention
and treatment’
Axis II Personality disorders
Axis III Physical disorder and conditions
Axis IV Severity of psychological stressors
Axis V Highest level of adaptive functioning in the last year
Criticisms of classification
There is no doubt that classification is needed in psychiatry
and it helps the clinicians to communicate with one another
about the diagnoses given to a patient and it helps to under-
stand the implications of the diagnoses, in terms of their
symptoms, prognosis, treatment and sometimes etiology.
However such classifications, on many occasions are criti-
cized as being inappropriate or even harmful. It can be argued
that allocating patients to a diagnostic category distracts
form the understanding of their unique personal difficulties.
It is important to combine the two because these qualities
can modify prognosis and these personal difficulties should
be taken into account for a holistic treatment of the disorder.
It is also worth noting that some conditions could be sub-
threshold and resemble the disorders in the classification but
do not meet full diagnostic criteria. It is not infrequent to see
such patients presenting to a variety of services other than
psychiatry. These sub-threshold conditions are however clin-
ically significant and it is important to recognize there condi-
tions to reduce the psychiatry morbidity or co-morbidity.
Diagnostic Criteria and Screening Questions
We intend to introduce the readers to the common psychi-
atric illnesses. This section should familiarize you with the
brief epidemiological details, diagnostic criteria and screen-
ing questions to be used in everyday practice.
A functional psychiatric illness should always be diag-
nosed after ruling out any physical condition that can
explain the presentation. For example, a middle-aged lady
with hypothyroidism may present with depression as the
only symptom. It is important to be aware of this aspect
as any psychiatric presentation could be mimicked by an
organic condition or by alcohol/illicit drug use.
Alcohol and substance use
The available epidemiological data suggests a combined
1 year prevalence rate of alcohol misuse and dependence
to be 7–10% (Kessler, McGonagle, Zhao, et al, 1994). An
understanding of the effects of alcohol and other substances
of abuse (tobacco, heroin, cannabis, cocaine) is important
for the practice of dentists. When such patients present
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 Section X – Appendices

with oral complications of prolonged substance misuse, in lasts for more than 2 weeks duration. It has to be differen-
addition to treating the oral condition it becomes impor- tiated from normal sadness. Such patients have impaired
tant to liaise with the mental health services to treat the patterns of mood, thoughts and behavior which sometimes
dependence. We aim to equip you to diagnose these depen- lasts for a long period of time. It causes a lot of distress to
dence syndromes with the diagnostic criteria which are the person and impairs his or her quality of life. It is also
common for all substances. accompanied by a high rate of suicide which is at least 7%
in men and 1% in women (Blair-West, Cantor, Mellsop, et al,
Three or more of the following to be present during the 1999; Weissman, Bland, Canino, et al, 1996). The 12 month
previous year prevalence of depression in the community is between 2 and
1. Strong desire or a sense of compulsion to take the substance 5% and the life time rate lies between 10 and 20% (Alonso,
(craving) Angermeyer, Bernert, et al, 2004). In the year 2000 the WHO
2. Difficulty in controlling substance taking behavior identified major depressive disorder as the fourth ranked
(loss of control) cause of disability and premature death in the world
3. Physiological withdrawal symptoms when substance use is
(Murray and Lopez, 1997). WHO has projected that by the
reduced, e.g., tremousless, anxiety and lack of sleep with
year 2020, major depression will rise in disease burden to
alcohol withdrawal
be second only to ischemic heart disease. This disorder is
very common all over the world with a life time preva-
4. Need to increase the intake over a period of time to get the
lence rate of 17% and a recurrence rate of more than 50%
same effect (tolerance)
(Kessler, McGonagle, Zhao, et al, 1994; Weissman, Bland,
5. Neglect of alternative pleasures or interests (salience)
Canino, et al, 1996). People with chronic disease have a
6. Continuing to use despite knowing it to be harmful
higher chance of developing depression. It is 40% for peo-
World Health Organization, 1992. ple with coronary artery disease and 25% for patients with
cancer (Musselman et al, 1998; Patten, 1999). Neurological
A commonly used screening tool for alcohol is CAGE which disorders associated with a higher frequency of depression
can be administered in a minute or less is shown in the include multiple sclerosis, Parkinson’s disease, head trauma
box below. and stroke (Patten et al, 2000; Poewe and Luginger, 1999).
Around one third of patients with depression develop alco-
CAGE Questionnaire hol or illicit substance misuse in their lifetime (Baker and
1. Have you ever felt you should cut down on your drinking? Dawe, 2005).
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
Most people with depression have five or six of the following
4. Have you ever had a drink first thing in the morning to
• Feeling sad most of the time (but may feel a little better in
steady your nerves or to get rid of a hangover (eye opener)?
the evenings)
Each Yes is scored 1 point. Score of ⱖ2 suggests significant
• Lose interest and enjoyment in life (anhedonia)
alcohol problems.
• Feeling tired easily with reduced energy levels
• Reduced concentration in day to day tasks
List of commonly misused drugs
• Find it harder to make decisions
• Amphetamines • Cocaine • Can’t cope with things that they used to
• Speedball • Heroin • Feel restless and agitated
• Cannabis, hashish • LSD • Lose appetite and weight
• Ecstasy, ketamine • Inhalants • Take 1–2 hours to get off to sleep, and then wake up earlier
• Steroids • Ether than usual
• GHB • Glue • Lose interest in sex
• Ritalin, diet pills, rush • THC, marijuana • Loss of self-confidence
• Barbiturates, Valium, Ativan • Speed • Feel useless, inadequate and hopeless
• Opium • Crack
• Avoid other people
• PCP, Angel dust • Morphine, methadone
• Feeling guilty about trivial issues
• MDA, MDMA • Crystal meth
• Feel irritable
• Grass • Freebase
• Feel worse at a particular time each day, usually in the morning

Depression • Having ideas or acts of self-harm or suicide

• Have a bleak and pessimistic view of the future
Depressive disorder also known as Major Depressive Dis-
World Health Organization, 1992.
order or Unipolar Depression is a psychiatric illness which

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Psychoses including schizophrenia and
delusional disorders
In psychotic illnesses patients suffer from strange and
unusual experiences and beliefs that are un-understand-
able. Schizophrenia is a mental disorder that affects around
1 in every 100 people. It can become severe and enduring
in a third. The commonest symptoms are hallucinations
and delusions.
A hallucination is a phenomenon where people hear,
see, feel or smell something when there is not anything (or
anybody) there to account for it. In functional psychotic
illnesses the commonest is hearing voices that seem to be
utterly real and coming from the outer world although other
people cannot hear them. These voice/voices can either talk
directly to the patient or talk to each other about the patient.
The patient might report that he/she is overhearing a con-
versation. Though the voice can be pleasant they are more
often rude, critical, and abusive, irritating and sometimes
commanding. These commanding hallucinations increase
the risk of harm to self and significant others.
Delusion is belief that the patient holds with complete
convictions although it seems to be based on a misinterpre-
tation or misunderstanding of the situation or event. When
we ask the patient why they believe in it, their reasons do not
make sense to us or they say that they cannot explain it and
‘they just know it’. So it is customary to define ‘delusion’
as a false unshakable belief, which is out of keeping with the
patient’s social and cultural background (Hamilton, 1984).
The commonest in this category are ‘paranoid’ delusions
and delusions of ‘reference’ or ideas of reference. The par-
anoid delusions or delusional ideas make the patient feel
persecuted or harassed. For example, the patient might
believe that he is being influenced by the neighbours who
are using special powers or technology. Another example
is where the patient starts to believe that his partner is
unfaithful. This belief is based on odd details that seem to
have nothing to do with sex or infidelity. In such cases
other people see nothing to suggest that the belief might
be true. Ideas of reference occur when the patients start
getting a special meaning in ordinary day-to-day events
and believe that they are specially connected to them. For
example, radio or television programs are about them or
people are communicating to them in odd ways, such as
through the color of cars in the street.
People with a more severe form of psychosis suffer from
‘thought disorder’ in which their thought process is mud-
dled. Their ideas are disconnected in such a way that it is
hard for other people to understand. Some patients experi-
ence as if their feelings or actions are controlled by an
external agency as if they are being controlled like a pup-
pet or a robot. So people experience as if their thought
process is being interfered with. It could be that their
thoughts are vanishing as though someone is taking them
out of their mind or as if the thoughts in their mind are not
their own, but someone else has put them in their mind.
Appendix2.indd e27
Appendix II – Mental Health and Its Relevance to Dentistry
While patients with schizophrenia experience any of
the above core psychotic symptoms, delusional disorders
are characterized by either a single delusion or a set of
related delusions which are usually persistent and some-
times lifelong. These delusions are clearly personal rather
than being subcultural and occur in the absence of brain
disease. Auditory hallucinations if present are only occa-
sional (World Health Organization, 1992). The delusional
disorders are generally more difficult to treat. Though
most of times psychosis is just picked up from the patient’s
conversation, the box below gives a list of screening
questions.
These questions only form a guide to clarify when you
suspect something abnormal and only the most relevant
questions should be asked keeping in mind the educational
and cultural background:
Persecution
How do you get on with others?
Do you believe that people are trying to harm you or make
your life miserable?
Is there a plot to cause harm to you?
Reference
Do people talk behind your back?
Do things seem specially arranged for you?
Do you see any reference to yourself in the TV or newspaper?
Grandiosity
How do you see yourself compared to others?
Do you have any special powers or abilities?
Are you specially chosen in any way?
Thought disorder
Are you able to think clearly?
Is there any sort of interference with your thinking process?
Do you think people around you can read your mind?
Always check for conviction, explanations and coping
How do you know this is the explanation?
Could it be your imagination or your ‘mind playing tricks’?
What do your family and friends think about this problem?
What do you intend to do about this problem?
Anxiety, stress-related and somatoform
disorders
Anxiety is a normal human feeling and we all would have
experienced it when faced with situations that we find dif-
ficult or threatening. The best example would be an exam or
interview. Often people refer to it as ‘stress’ which is con-
fusing and can mean different things. On the one hand, it
may refer to things that make one anxious or on the other
hand it could be a reaction to being faced with anxiety pro-
voking situations. It is important to differentiate ‘anxiety’
from ‘worry’ and ‘fear’. When anxiety is a result of a con-
tinuing problem like financial problem we call it ‘worry’.
A sudden response to an immediate threat like looking
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 Section X – Appendices
over a cliff is ‘fear’. Both fear and anxiety can be helpful,
helping us to avoid dangerous situations, making us alert
and motivating us to deal with problems. However if it
becomes too strong or goes on for too long it can interfere
with our daily activities and make our lives miserable.
Anxiety cause numerous physiological (in the body)
symptoms and cognitive symptoms (in the mind) shown in
two separate boxes below.
Physiological symptoms of anxiety
• Irregular hear beats (palpitations)
• Sweating
• Muscle tension and pain
• Shakes and tremors
• Butterflies in the stomach
• Tightness in the chest
• Breathing heavily
• Dizziness
• Faintness
• Indigestion
• Diarrhea
Cognitive symptoms of anxiety
• Fear of ‘going mad’
• Fear of ‘passing out’ or ‘imminent death’
• Fear of having a ‘heart attack’
• Fear of a serious physical health problem
• Feeling worried all the time
• Feeling excessively tired
• Unable to concentrate
• Feeling irritable
• Sleep problems
Phobias and social phobia
Phobia is fear of a particular situation or particular things
that are not dangerous and which most people do not find
it dangerous. We all have fears about things such as height
and spiders but, for most of us, these fears do not interfere
with the way we lead our lives. These fears are called pho-
bias only when they interfere with things we would other-
wise enjoy or do easily. A person with phobia has the same
intense symptoms of anxiety described above but these
arise only in the particular situations that frighten them. At
other times they do not feel anxious. For example, a person
with phobia of dogs is comfortable when there are no dogs
around. However phobia makes the person avoid situations
in which they know they will be anxious. This ‘avoidance’
actually makes the phobia worse as time goes on. Over time
the person’s life becomes increasingly dominated by the
precautions he needs to take in order to avoid the fearful
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Appendix2.indd e28
situation. This ‘avoidance behavior’ keeps expanding to
include more and more situations and circumstances. The
sufferer usually knows that there is no actual danger, may
feel silly about this fear but still is unable to control it.
Such a phobia can start after a distressing or a traumatic
experience, many a times in early life.
Many of us worry before meeting new people and before
going to parties but once we are there we can cope and
enjoy the situation. Some people become very anxious about
such situations, cannot enjoy them and at worse totally
avoid such social situations. This condition is called ‘social
phobia’. Such people tend to worry about becoming the
center of attention wherever they find themselves amongst
people. They worry that everybody is looking at them and
watching what they are doing. At their worst, these feel-
ings of fear and bodily symptoms can end up in a ‘panic
attack’. A panic attack lasts for a few minutes during which
the person feels overwhelmingly anxious and is terrified
of losing control, going mad or dying. These feelings reach
a peak and then pass off rapidly leaving the person feeling
weak and exhausted.
Panic disorder
Panic disorder is a type of mental illness with recurrent
and unexpected intense episodes of anxiety called as panic
attacks. A panic attack is characterized by intense appre-
hension and terror accompanied by physical symptoms like
palpitations, chest pain, dizziness, sweating and difficulty
in breathing. These attacks have an abrupt onset and peak
in intensity within 10 minutes. These attacks are not associ-
ated with any external event or situation and come out of
the blue. Such episodes often result in calls to paramedics
and visits Accident and Emergency Department. Panic dis-
order could sometime be a lifelong illness that remains
only partially responsive to treatment. Women appear to
have more severe form of the disease that men (Yonkers,
Zlotnick, Allsworth, et al, 1998) and is much more com-
moner in women (Barzega, Maina, Venturello, et al, 2001;
Kessler, McGonagle, Zhao, et al, 1994).
Agoraphobia
The term ‘agoraphobia’ means ‘fear of open spaces’. Such
people not only fear open spaces but also presence of a crowd.
They fear not having an immediate and easy escape to a safe
place (usually home). Such patients generally have a fear of
leaving home, fear of entering shops, crowds, public places,
or of traveling alone in trains, buses, or planes. The severity
of anxiety symptoms and the extent of avoidance varies from
patient to patient. However for some people it is the most
incapacitating of all phobic disorders and they become com-
pletely housebound. Some people are terrified by the thought
of collapsing and being left helpless in the public. The lack of
an immediately available exit seems to be a key feature in
these patients with agoraphobia who tend to be women in
11/6/2009 3:54:36 PM

early adult life. Depression and social phobia may also be
present but do not dominate the clinical picture.
People feel grief-stricken, depressed, anxious and angry
after a traumatic experience. A traumatic event is where
one is in danger; one’s life is threatened or sees other peo-
ple dying or being injured. The condition is called post-
traumatic stress disorder (PTSD) when one starts re-living
the trauma again and again in the form of ‘flashbacks’ dur-
ing the day or ‘nightmares’ in sleep. In addition they start
avoiding related situations, become emotionally numb and
‘hyper-vigilant’, unable to relax. The emotional reaction in
stress is often accompanied by other symptoms of anxiety
listed in the box above.
The questions in the box below help you to screen for
the anxiety disorders.
Panic attacks
• Have you had spells or attacks when you suddenly felt
anxious, frightened, uncomfortable or uneasy, even in
situations where most people would not feel that way?
Did the spells surge to a peak, within 10 minutes of
starting?
• Do you feel anxious or uneasy in places or situations where
you might have a panic attack or panic-like symptoms, or
where help might not be available or escape might be
difficult: like being in a crowd, standing in a queue, when
you are away from home or alone at home, or when crossing
a bridge, traveling in a bus, train or car?
Social phobia
• Have you been fearful or embarrassed of being watched,
being the focus of attention, or fearful of being humiliated?
This includes things like speaking in public, eating in public
or with others, writing while someone watches, or being in
social situations.
PTSD
• Have you ever experienced or witnessed or had to deal with
an extremely traumatic event that included actual or
threatened death or serious injury to you or someone else?
Examples of traumatic events include serious accidents,
sexual or physical assault, a terrorist attack, being held
hostage, kidnapping, fire, discovering a body, sudden death
of someone close to you, war, or natural disaster.
• Have you had a dental appointment or a medical
intervention in the past which you found significantly
traumatic. What was the reason you found it to be traumatic.
Was it because you were not adequately prepared due to
lack of information as to what was going to happen.
Obsessive compulsive disorder (OCD)
We commonly use phrases like, ‘He’s an obsessive cricket
fan’, and ‘She’s a compulsive liar’. We use these phrases
when people do things again and again, and others cannot
see any reason for it. The essential features of this disorder
Appendix2.indd e29
Appendix II – Mental Health and Its Relevance to Dentistry
are recurrent obsessional thoughts and compulsive acts.
Obsessions are patient’s own thoughts which are repetitive
and intrusive. These thoughts are almost invariably distress-
ing to the patient, because they are violent or obscene or
simply because they are perceived to be senseless. The per-
son often tries to resist these thoughts but is unsuccessful.
Obsessional thoughts could be in the form of ideas, images
or impulses that enters the individual’s mind again and
again in a stereotyped fashion. Compulsive acts are also
known as rituals. These are stereotyped behaviors repeated
again and again. They are not inherently enjoyable and
they do not result in the completion of any useful thoughts.
The individual often views the compulsions to be reducing
the anxiety caused by the obsessions. Usually these repeti-
tive acts are considered to be pointless and the patient
tries to resist them, only to yield to them when the anxiety
builds up. However in very long standing cases the resis-
tance may be minimal. There is often a close relationship
between obsessional symptoms and depression. The com-
monest ritual seen is frequent hand washing as a result of
obsessive thoughts that one might be contaminated by
germs, dirt or HIV. The other commonly seen compulsion
is a checking behavior.
About 1 in 50 people suffer from OCD at some point in
their lives. Men and women are equally affected. It affects
work, relationships and family life of the patient. People
with a severe OCD also cause burden on their carers. Some
people with mild OCD improve without any treatment.
Some will slowly get worse and some get worse when they
are stressed and depressed. The mainstay of treatment for
OCD continues to be talking therapies like exposure and
response prevention and guided self-help. Antidepressant
medications can be used alone or in combination with
talking therapies for moderate to severe OCD.
Hypochondriasis
Patients with hypochondriasis are preoccupied by a fear of
having a serious disease based on the misinterpretation of
their bodily symptoms (American Psychiatric Association,
1994). This serious preoccupation persists despite negative
investigations and causes distress with impaired function-
ing of the patient. The central and diagnostic clinical fea-
ture is the preoccupation with the idea of having a serious
medical condition, usually one which will lead to death
or serious disability. The patient usually ruminates repeat-
edly on this possibility. The minor and insignificant bodily
abnormalities, normal variants, normal functions and minor
ailments will be interpreted as signs of the serious disease.
The patient will consequently seek medical advice and inves-
tigation but is unable to be reassured by the negative results.
Such patients may be able to accept that their worries are
groundless but nonetheless are unable to stop dwelling
and acting on them. Such beliefs are more often than not
over-valued ideas. However this belief can be of a delusional
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 Section X – Appendices
intensity when the patient should be treated as for a delu-
sional disorder. Otherwise antidepressants, behavioral therapy
and cognitive behavioral therapy (CBT) are the mainstay
of the treatment for hypochondriasis.
Body dysmorphic disorder
Body dysmorphic disorder (BDD) is characterized by ‘devas-
tating’ preoccupation with an imagined defect in appearance
and marked distress over the supposed deformity (American
Psychiatric Association, 1994). Though the focus of patients
with BDD is by definition on physical appearance, data
exists on patients with BDD having obsessional concerns
with odor (Hollander and Aronowitz, 1999). BDD is also
known as dysmorphophobia. It is an intriguing and some-
times difficult to treat condition that often mystifies the
clinicians. This disorder is characterized by distressing and
impairing preoccupation with a non-existent or slight defect
in appearance. Although BDD symptoms may sound trivial
the disorder can cause severe distress and can lead to sui-
cide. Individuals with BDD are preoccupied with the idea that
some aspects of their appearance is unattractive, deformed
or ‘just not right’ in some way. Concerns usually focus on their
face or head but can involve any area of the body (Phillips
and Diaz, 1997; Phillips, et al, 1993). Concerns with bodily
asymmetry, for example, ‘uneven’ buttocks are also common.
BDD by proxy consists of a preoccupation with supposed
flaws in another person’s appearance, which may lead to
insistence that the other person should have surgery or
dermatological treatment.
The majority of BDD patients seek often costly non-
psychiatric treatments (Phillips, 1996) and may also present to
the dental practitioners in the first instance for surgical treat-
ment. However most BDD patients appear dissatisfied with
such treatment and many dislike their new appearance even
more (Andreasen and Bardach, 1977). Multiple procedures
may be received in search for a cosmetic solution to this psy-
chiatric problem before it comes to psychiatrist. Occasionally,
dissatisfied patients sue, or even become violent towards
the physician. There are rare reports of patients trying to per-
form their own surgery, as did one man who cut his nose open
and tried to replace his own cartilage with chicken cartilage.
The mainstay of evidence based treatments for BDD includes
selective serotonin reuptake inhibitors (SSRI) and CBT.
Interesting Interface between ‘Dentistry’
and ‘Psychiatry’
Disorders on the Psychotic Spectrum
Orofacial phantom pain
Current day dentists are often faced with challenges when
patients present with orofacial pain. In the current day
e30
Appendix2.indd e30
competitive practice there is always an urgency to treat
conditions associated with the pain. More often than not
the clinical dilemma needs to be resolved quickly and
decisively. Such situations impel the clinician to perform
procedures designed to eliminate pain such as endodontic
therapy or tooth extractions or to construct new and dif-
ferent dentures (Marbach, 1996). Though this urgency is
almost palpable, such urgent situations create the poten-
tial for failure. It is thus essential to be aware of the three
putative neuropathologic facial pain disorders:
1. Phantom tooth pain
2. Intraoral stump pain
3. Phantom bite syndrome
1. Phantom tooth pain Reports on tooth pain of obscure
origin are relatively recent (Harris, 1974). The term phantom
tooth pain was first used in 1978 (Marbach, 1978), and since
then the condition has been validated extensively as a clin-
ical entity (Marbach, 1993a; Marbach, 1993b; Pollmann,
1984; Rees and Harris, 1979). Phantom tooth pain is the
most common type of orofacial phantom pain reported.
It usually follows dental or surgical procedures such as
pulp extirpation or tooth extraction. It is characterized by
persistent tooth ache with no identifiable cause. Neither
repeated endodontic treatment nor tooth extraction renders
the affected area free of pain. On the contrary, procedures
and other surgical interventions such as trigeminal rhizot-
omy and microvascular decompression frequently exacer-
bate pain and may even enlarge its distribution. Other terms
for phantom tooth pain, such as atypical odontalgia (Brooke
and Merskey, 1994), idiopathic odontalgia and atypical facial
pain, also are in use (Bates and Stewart, 1991).
The pain is described as a constant, dull, deep ache with
occasional spontaneous sharp pains. There are no refrac-
tory periods. Peripheral stimuli can momentarily exacer-
bate the pain but have no prolonged influence. Radiographic
and laboratory tests are negative. Sleep is undisturbed by
pain or other phantom sensations. Many patients report a
brief symptom-free period on awakening in the morning.
It resembles other phantom pain syndromes that com-
monly arise following amputation and injury (Marbach,
1996). Phantom tooth pain has only been reported in
adults and none in children (Marbach, 1996).
2. Intraoral stump pain Stump pain is a frequent squeal
of limb amputations. Davis cited this pain as a major cause
of prosthetic limb rejection among amputees (Davis, 1993).
Sherman and colleagues suggested that denture pain is the
intraoral equivalent of limb stump pain (Sherman, 1989).
Stump pain does not disappear with time or with adjustments
or replacements of the prostheses (Marbach, 1996). The
health and financial conditions of these patients improve
on treatment directed towards stump pain which is focused
away from mechanically based etiologies (Marbach, 1985).
The onset of pain is usually associated with an injury to
a peripheral nerve. Pain is often worse at the site of the
11/6/2009 3:54:36 PM

original trauma, although in chronic cases they have dif-
ficulty in localizing the pain.
3. Phantom bite syndrome Phantom bite syndrome is
often associated with an inability to adapt to changes in
dental occlusion (Marbach, 1978; Marbach, 1985). Non-
painful phantom limb phenomena are common among
recent amputees but usually fade with time (Jensen, Krebs,
Nielsen, et al, 1984). Recently orofacial phantom bite syn-
drome has been viewed as a psychiatric disorder (Bonica,
1991; Jensen, Krebs, Nielsen, et al, 1984; Marbach, 1978;
Marbach, 1985). This interpretation has been revised in light
of current research (Jensen, Krebs, Nielsen, et al, 1984;
Melzack, 1993; Sherman, 1989). Though phantom bite syn-
drome can occur at any stage of dental treatment, it is
typically associated with the construction of extensive
prosthesis in all age groups and the beginning of orthodon-
tic treatment in adolescents (Marbach, 1996). They usually
complain of continuous discomfort and are frequently dis-
tressed by the lack of familiarity of their own bite (Marbach,
1996). Seeking relief from phantom bite syndrome often
becomes an expensive and lengthy effort towards restora-
tion of one’s original but ‘lost’ bite (Marbach, 1978; Marbach,
1985). Success is rarely if ever obtained. Treatment there-
fore should be focused on prevention, early detection and
patient education.
Delusional bad odor
Bad breath is also known halitosis, it is a common concern
found in millions of people. There seems to be no reliable
way to assess breath odor. Some people develop faulty per-
ceptions about having a bad breath. Sometimes it affects
their entire life. On the other hand, some people who have
halitosis remain unaware of their condition. Every patient
has a breath odor self-image. This self-image ranges from
little or no distortion to severe psychopathology (Eli, Baht,
Koriat, et al, 2001). Because these people go to a dentist with
a complaint of oral malodor, it becomes the responsibility
of dental practitioners to identify this psychopathology. It is
important for dentists to consider both psychological and
physiological factors while diagnosing and treating such
cases.
Various researchers have attempted to understand the
distortions in self-perception of odors, including oral mal-
odor, in the context of various psychiatric disorders
(Davidson and Mukherjee, 1982; Pryse-Phillips, 1971). One
relevant example is patients who complain of various body
odors (auxiliary, fecal or genital) that appear to have no
objective basis. These patients may have somatic delusions
or an olfactory reference syndrome (ORS) (Pryse-Phillips,
1971). Causes of ‘delusional halitosis’ were presented in
the literature by Davidson and Mukherjee (Davidson
and Mukherjee, 1982), Iwu and Akpata (Iwu and Akpata,
1990) and Oxtoby and Field (Oxtoby and Field, 1994).
Halitophobia also may be considered in the context of
Appendix2.indd e31
Appendix II – Mental Health and Its Relevance to Dentistry
BDD. Halitophobics often display other psychological phe-
nomenon, such as compulsive toothbrushing and with-
drawal from social interactions (Rosenberg, 1996).
Olfactory reference syndrome
Patients sometimes present with persistent olfactory con-
cerns or preoccupations with personal odor (Malasi, el, Mirza,
et al, 1990; Pryse, 1971; Stein, Le, Bouwer, et al, 1998;
Videbech, 1966). The term ‘olfactory reference syndrome’
(ORS) has been introduced to differentiate primary olfactory
concerns from those seen as a consequence of other dis-
orders such as schizophrenia, depression or temporal lobe
epilepsy (Pryse, 1971). It is still controversial whether ORS
is truly a unique disorder or merely a part of the symptoma-
tology of other psychiatric conditions (Lochner and Stein,
2003). However it has been noted that most patients with
primary ORS are young men without concurrent psychiat-
ric disorders (Pryse, 1971). Arguably, the principal symp-
tomatology of ORS has sufficient overlap with anxiety and
somatic disorders.
Case vignette
A 22-year-old male presented with the belief that he had
malodorous breath (halitosis) and a foul odor emanating from
his armpit, feet, and anal region. This persistent preoccupation
had begun in early adolescence, but the intensity had
increased significantly over the past 7 months. Halitosis was
his main concern. But collateral information from his parents
confirmed his excessive washing and frequent change of
clothes. His embarrassment about the perceived halitosis
gradually caused increasing social withdrawal and isolation
and also resulted in depressive symptoms. He remained
convinced that the halitosis had persisted, despite reassurance
to the contrary by his physician and close family members.
Schizophrenia – dental implications
Dentists who are familiar with the signs and symptoms of
schizophrenia are likely to feel more secure while treating
patients with schizophrenia. It makes the dentist more con-
fident while obtaining consultative advice from the patient’s
psychiatrist. Dentists can provide the full range of service
to such patients and constitute to the psychotherapeutic
aspect of management. In addition to being able to commu-
nicate effectively with such patients, the dental treatment
may need to be modified because of the patient’s impaired
ability to think logically. It is very important for all dentists
to be aware of the local and systemic effects of psychiatric
medications and the adverse interactions between these
drugs and medications used in dentistry.
Schizophrenia can be conceptualized as a group of dis-
orders, with variable presentations, best described in three
different dimensions: positive symptoms, disorganized symp-
toms and negative symptoms. The positive symptoms are
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 Section X – Appendices
the exaggeration or distortion of normal functions, most
commonly delusions and hallucinations which are described
earlier in the chapter. ‘Disorganized’ symptoms are inferred
from patient’s speech and are also known as ‘thought dis-
order’. It is manifested as rapid shifts between topics that
either have a loose logical association or are completely
unrelated. They may also exhibit inappropriate affect man-
ifested by childish silliness and unpredictable agitation.
(Andreasen, Arndt, Alliger, et al, 1995; Marder, 1996). They
also exhibit a range of neurocognitive impairments in the
areas of memory, attention and executive functions, which in
turn impairs their vocational and social adjustment (Green,
1996). Negative symptoms are less dramatic but equally
debilitating. They include reduced emotional responsiveness
(flat affect); reduced speech output and poor thought con-
tent; inability to plan, initiate and persist in goal directed
activities (avolition) and poor self care in terms of washing,
bathing and cooking. They also show social withdrawal and
loss of pleasure in previously enjoyed activities (anhedonia)
(1994; Kaplan and Sadock, 1995).
Substance abuse frequently accompanies schizophre-
nia. The prevalence rate of alcohol abuse in schizophrenia
is as high as 63% in some studies (Dixon, 1999). Other
commonly abused drugs are cannabis and cocaine. Some
patients seem to self medicate their positive symptoms
with these illicit drugs which in turn makes the psychosis
worse. Abuse of these substances strongly correlates
with medical and psychosocial problems like inadequate
diet, homelessness, poor compliance with medications and
multiple episodes of the disorder (Dixon, Postrado,
Delahanty, et al, 1999). More than 3/4th of patients with
schizophrenia smoke and this is frequently associated with
emphysema, lung cancer, cardiac disease and oral cancer
(McEvoy and Brown, 1999).
Patients with schizophrenia are often having a disinterest
in performing appropriate preventive oral hygiene techniques
(Friedlander and Liberman, 1991; Thomas, Lavrentzou,
Karouzos, et al, 1996). This in turn leads to the development
of advanced oral disease. This is compounded by reduced
access to care, prolonged hospitalizations, impaired finances
and paucity of clinicians who are comfortable in caring
such people. Some antipsychotics namely chlorpromazine
and thioridazine cause profound hyposalivation through
their anticholinergic effects (Sreebny, 1989). This is wors-
ened by the co-administration of antiparkinsonian agents
to counteract the extrapyramidal side effects (EPSE) of the
conventional (dopamine agonist) antipsychotics. The resul-
tant hyposalivation causes intensification of periodontal dis-
ease and rapid caries progression (Gupta, Tiwarri, Salimeno,
et al, 1993). So a lot of people with schizophrenia have
a higher requirement for periodontal treatment, dental
restorations and dental extractions (Velasco, Machuca,
Martinez-Sahuquillo, et al, 1997). The conventional anti-
psychotics have adverse side effects, especially the move-
ment disorders that mimic neurological diseases. These
e32
Appendix2.indd e32
movement disorders frequently have an orofacial compo-
nent and are seen to develop in a time dependent fashion.
These movement disorders are caused by the blockade of
basal ganglia dopamine D2 receptors in the extrapyramidal
system (Holloman and Marder, 1997).
Effects of antipsychotic drugs on orofacial movements
Acute diagnoses which generally manifest within the first
5 days of starting treatment:
• Oculogyric crisis (eye turned upwards)
• Torticollis (head turned sideways)
• Retrocollis (head turned backwards)
• Trismus (forced closing of the mandible)
• Laryngospasm
• Spasm of neck muscles
• Tongue protrusion
Pseudoparkinsonian side effects generally develop in
1–3 months after therapy
• Reduced eye blinking
• Monotonous and soft speech
• Mask-like face
• Cogwheel rigidity
Tardive dyskinesia is slow to develop and is generally seen in
7 to 10 years of antipsychotic use. It is characterized by
rhythmical involuntary movements of
• Mouth (ex, puckering)
• Face (ex, puffing of cheeks)
• Jaw (ex, chewing movements)
• Tongue (ex, protrusion)
Clozapine is another medication to be aware about. It is an
atypical antipsychotic used in patients unresponsive to other
medications (Breier, Malhotra, Su, et al, 1999). Clozapine
has a unique added advantage of reducing the cravings for
alcohol and illicit drugs (Volavka, 1999). About 0.5 to 1%
of patients on clozapine develop bone marrow suppression
causing agranulocytosis and granulopenia (Worrel, Marken,
Beckman, et al, 2000). This prevents clozapine from being
used as a first line drug. Thus all patients on clozapine
should have periodic WBC count (1998). Although clozapine
is a potent anticholinergic agent, it has a unique, unexpected
side effect of sialorrhea in 85% of patients (Clark, 1992).
Anxiety and Depressive Disorders
Depression and dental implications
A depressive disorder may be associated with extensive
dental disease (Baker and Dawe, 2005). Patients may seek
dental treatment before becoming aware of their psychiat-
ric illness (Gatchel, Garofalo, Ellis, et al, 1996). Depression
is often associated with a disinterest in performing appro-
priate and timely oral hygiene techniques. It can also be
11/6/2009 3:54:37 PM

associated with a cariogenic diet, diminished salivary flow,
rampant dental caries, advances periodontal disease and oral
dysesthesias (Friedlander and Mahler, 2001). Side effects of
antidepressant medications increase the incidence of den-
tal diseases including xerostomia (Gerber and Lynd, 1998).
An appropriate dental management in such patients would
include a good dental education, the use of saliva substitutes
and anti-caries agents containing fluoride. Special precau-
tions should be taken and every potential drug interaction
should be kept in mind while prescribing analgesics and
local anesthetics (Callahan, 1996).
Depression in chronic facial pain
Depressive illness is a common and a serious disorder that
affects atleast 20% of women and 10% of men during their
life time (Kessler, McGonagle, Zhao, et al, 1994). Approxi-
mately 15% of these people eventually commit suicide
(Angst and Hochstrasser, 1994; Coppen, 1994). Depression
has a high comorbity with chronic facial pain, making
it important for dental practitioners to be able to identify
depressive symptoms in dental patients presenting with
facial pain. The rate of depression has been shown to be
as high as 40 to 80% in patients with chronic facial pain
(Gallagher, Marbach, Raphael, et al, 1991; Korszun et al,
1996). More than 40% of patients with chronic facial pain
are refractory to treatment (Friedlander and Mahler, 2001).
Thus early identification and optimal treatment of co-
morbid depressive disorder will have a significant impact
on the treatment outcome for these patients.
Blumer and Heilbronn (Blumer and Heilbronn, 1982)
suggested that patients with chronic pain have an under-
lying depression that is masked and represented only by
somatic symptoms that are not accompanied by the usual
mood symptoms, making it more difficult for the dental
practitioners to recognize depression. On the other hand,
some authors have conceptualized depression as a second-
ary maladaptive response to chronic pain (Dworkin,
1991).
As a dental practitioner the most important factor is hav-
ing awareness of depression as a medical disorder and hav-
ing an openness to recognize the less obvious presentations
of a depressive disorder. If clinicians themselves conceptu-
alize depression as a mental disorder or a character defect
and do not understand the neurological basis and treatability
of depressive conditions, they will not only fail to recognize
this serious condition but will also convey this prejudice
to their patients. Patients may also be resistant to even con-
sidering a diagnosis of depression particularly when they
are consulting a dentist for what they perceive to be a
physical condition such as jaw pain. Because of the time
constrains in a busy dental practice it might be worth
while administering a depression rating scale such as the
Beck Depression Inventory (Beck, Ward, Mendelson, et al,
1961) for all patients presenting with chronic facial pain.
Appendix2.indd e33
Appendix II – Mental Health and Its Relevance to Dentistry
Recognizing depressive symptoms in patients with chronic
pain is particularly challenging as many symptoms second-
ary to chronic pain are also prime symptoms of depressive
illness. For example, patients with chronic pain have a
resulting poor sleep, lethargy, irritability and weight loss
due to pain while eating, which are the core symptoms of
depression. It is also important to screen for co-morbid alco-
hol and substance abuse in such patients. A broad multi-
disciplinary approach to the diagnosis and treatment will
improve treatment outcomes of such patients.
Antidepressant use – importance for dental practice
Many dental patients are prescribed antidepressants for
diverse therapeutic reasons such as pain control, insom-
nia, smoking cessation, substance abuse and eating disor-
ders. However antidepressants taken with other drugs may
increase the risk of complications that require special den-
tal precautions and care. Patients receiving antidepressant
therapy commonly complain of decreased salivation and
changes in salivary viscosity (Astor et al, 1999). Xerostomia
(Peeters et al, 1998), orthostatic hypotension (Peeterset al,
1998) and cardio-toxicity (Roose et al, 1998) are signifi-
cant adverse effects of certain antidepressant medications
especially when they are taken in combination with other
medications (Fox, 1998). Chronic xerostomia can cause oral
mucosal changes, increased coronal and root caries suscep-
tibility, candidiasis, partial loss of taste acuity, periodontal
disease, and difficulty in swallowing and functional pros-
thetic problems (Astor et al, 1999). In patients aged 60 years
or older, Thomson and colleagues (Thomson et al, 1995)
reported a higher root caries index value for those on anti-
depressant therapy.
Precautions related to orthostatic hypotension include
shorter dental interventions, positioning the patient up right
in the dental chair, avoiding sudden postural changes, using
caution in prescribing medications which cause orthostatic
hypotension.
The injection of local anesthetics containing vasocon-
strictors often causes an increase in blood pressure. A rare
paradoxical hypertensive reaction may occur when
patients taking drugs with alpha-1 adrenergic blocking
activity (such as tricyclic antidepressant) are given with a
local anesthetic containing vasoconstrictor (such as epi-
nephrine). This reaction occurs as epinephrine is unable to
bind to the blocked alpha-1 receptors, instead interacts
with available beta-2 receptors causing vasodilatation and
a resultant paradoxical hypotensive reaction (Keene et al,
2003). Dental precautions include using a minimal quan-
tity of local anesthetic with sympathomimetic vasocon-
strictor and taking care to prevent intravascular injections.
Use of epinephrine containing homeostatic agents is con-
traindicated. All these precautions are only in addition to
routine monitoring of blood pressure and other vital signs
(Yagiela, 1999).
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 Section X – Appendices
Eating disorders – dental implications
Dentists are likely to encounter patients who have eating
disorders and they have an important part to play in the
overall care of these patients. There are two major catego-
ries of eating disorders namely anorexia nervosa and buli-
mia nervosa. Anorexia occurs in upper and middle class
families while bulimia presents across all social classes
(Hugo and Lacey, 1996).
Anorexia is aversion to food, which can be conceptual-
ized as resulting from a complex interaction between bio-
logical, individual and family factors. This aversion to food
leads to severe weight loss and its complications, both phys-
iological and psychological. There are two subtypes of
anorexia, ‘restricting’ and ‘binge/purge’ types. The differ-
ence between these two sub-categories is based on whether
the person regularly engages in binge eating or self-induced
vomiting (SIV), excessive exercise or misuse of laxatives,
diuretics or enemas. Bulimia is even more common and
is characterized by overeating followed by inappropriate
compensatory behaviors with normal body weight.
Patients with bulimia nervosa often present with bilat-
eral and occasional unilateral parotid gland swelling. The
incidence of parotid gland swelling is 10–15% in people
with bulimia (Brady, 1985). The submandibular salivary
gland is involved infrequently. The exact pathogenesis of
these glandular enlargements has not been determined. It
is generally accepted that multiple emetic episodes cause
an autonomic neuropathy (Ascoli, Albedi, De Blasiis, et al,
1993). With sympathetic nerve impairment, individual
acinar cells enlarge and lead to clinically visible gland
swelling (Ascoli, Albedi, De Blasiis, et al, 1993). Such an
asymptomatic bilateral parotid enlargement often presents
a diagnostic dilemma to the dentists. As these patients
with bulimia nervosa and parotid gland swelling are usu-
ally secretive about their SIV (purging), the diagnosis will
have to be made by conducting a thorough clinical exam-
ination and serum electrolyte study. Early recognition and
prompt diagnosis when such patients present to the den-
tists can avoid the later serious medical complications. The
need for these patients to seek psychiatric care and dis-
continue SIV is mandatory.
Eating disorders have various oro-dental adverse effects.
Holst and Lange in 1939 coined the term ‘perimylolysis’ to
describe the distribution of erosion on the upper palatal
surfaces secondary to vomiting, reflux and regurgitation
(Holst and Lange, 1939). Several research studies till date
have shown that SIV results in increased frequency of
erosion on palatal surfaces (Hellstrom, 1977). Whether the
caries experience in eating disorder individuals is greater
than in normal population remains unclear (Hurst et al,
1977). Salivary flow increases dramatically prior to vomit-
ing because the medullary center that controls vomiting is
connected to salivary nuclei (Edgar, 1992). With respect to
SIV, the stimulated salivary flow should therefore be altered.
e34
Appendix2.indd e34
Research has discovered reduced bicarbonate in bulimics
along with increased salivary viscosity (Edgar, 1992). One
study has found increased frequency of periodontal dis-
ease in patients with eating disorders (Touyz, Liew, Tseng,
et al, 1993). Angular cheilitis, candidosis, glossitis and oral
mucosal ulceration are possible sequelae of nutritional defi-
ciency. There has not been any report of malignant change
associated with SIV (Brady, 1980).
The dental care demanded by individuals with eating
disorders is very challenging. Although the dentist might
suspect vomiting as the cause of erosion, these patients
will not readily admit to such behavior because they can
be highly secretive and embarrassed by it. The patients’
motivation to reduce the frequency of SIV will increase
once the dentist is able to openly relate the progress of
dental erosion with the vomiting. Toothbrushing after
vomiting is generally regarded as inadvisable because
the softened, demineralized surface is more susceptible
to toothbrush abrasion (Milosevic et al, 1997; Robb et al,
1995).
Patients whose teeth have been damaged as a conse-
quence of an eating disorder are most likely to present first
to the dentists. In many cases the dentist is in a position to
assist in making the initial diagnosis and can influence
progress of the medical and psychological management of
the disorder.
Management of Psychiatric Disorders
Broad Principles
Some patients who receive psychiatric treatment for men-
tal health problems may be reluctant to admit it. This is
most often because of the perceived stigma associated with
mental illness. It is important and could be quite tricky for
a dentist to overcome such barriers and obtain the neces-
sary information. It always helps to take a supportive and
non-judgmental attitude and advice patients that such infor-
mation will be held confidential and also that it is indis-
pensable to provide a safe dental care.
Patients with mental health problems may be uncoop-
erative and irritable during dental treatment. They may
appear unappreciative and may seem to have numerous
complaints that are inconsistent with the objective find-
ings (Korszun and Ship, 1997). It is always beneficial to
liaise with the patient’s psychiatrist before beginning any
dental treatment. Information requested should include
atleast the latest mental state, risk assessment and the list
of psychotropic medications. In addition a history of alco-
hol and illicit drug use is always useful. Such patients
should undergo a liver function test, full blood count
and coagulation profile before commencing the dental
treatment.
11/6/2009 3:54:38 PM

Importance of Interpersonal Communication
Skills with Special Emphasis on Dental
Phobia
Communication skills – why bother?
From personal experience of one of the authors, we state
the obvious that, dentists should remember that the patient
cannot speak with a wide open dry mouth and with dental
instruments in their mouth. They should probably ask ques-
tions that generate a yes/no type of response. Also, at the
outset, it is useful to lay down the ground rules such as, ‘if
in pain, raise your left hand’.
Patients seeking dental treatment have apprehensions
about the nature of their problem and the procedure
involved. One of the common misconceptions that people
have is that all dental procedures are painful. Also, the
fear of injections and the sound and sight of drills and
other instruments keeps many patients away. This may
lead to patients postponing visits to their dentists or totally
avoiding it. The estimates of dental anxiety in general
population varies between 6% to as high as 20% (Rouse
and Hamilton, 1990).
Dentist-patient relationship rests a lot on the interper-
sonal communication. This also has a significant impact in
allaying dental anxiety. Corah et al (1985) have reported
that anxiety during treatment was influenced by patient
satisfaction with the dentist’s technical competence,
understanding and communication skills (Corah et al,
1985).
It needs to be stressed that every doctor has to approach
his patients with warmth and have a basic respect for them
and acknowledge the distress that the person seeking help
may be going through.
Importance of explaining the procedure to the
patients
Dentists often have to deal with anxious clients. Helping
patients overcome such anxiety can reduce the rates of
missed appointments and also better compliance on the
part of the patient during the treatment session. Various
ways of doing it can be employed such as using models,
charts or diagrams and video clippings. It is important to
check patient understands at every step. The very step of
explaining the procedure helps patients to be mentally
prepared and allays their anxiety. It is also helpful to
obtain a verbal consent from the patient ensuring that
they are ready for the procedure.
In addition, creating a conducive environment for the
patient also helps. A survey by Bare and Dundes has shown
that a majority of anxious patients found it helpful to have
gentle music in the background, magazines and books,
adorned walls and a slightly cool temperature in the waiting
area (Bare and Dundes, 2004).
Appendix2.indd e35
Appendix II – Mental Health and Its Relevance to Dentistry
Dealing with dental anxiety/phobia
Bare and Dundes have summarized from past research the
reported causes of dental anxiety (Bare and Dundes, 2004).
Some of the common ones are:
❑ If patients have had previous painful experiences
❑ Belief that painful treatment is inevitable
❑ If they feel that they lack control over the situation, includ-
ing the inability to stop a procedure they find unpleasant
❑ Lack of understanding of the procedure that the dentist
performs
❑ Patients having a general fear of the unknown
❑ Media coverage or hearing from acquaintances of fright-
ening tales of dentists or procedures
❑ Experienced detached treatment by a dentist
❑ Having fears of experiencing ridicule because of how
they react to situations arising during their visit.
It is important to provide information to the patient as
soon as possible about the nature of the problem and what
they can expect during and after the treatment. It is known
as ‘informational control’ and it reduces dental anxiety
(Levitt et al, 2000).
Maggirias and Locker reported that patients who per-
ceive that they have little control over the procedure were
more likely to report pain (Maggirias and Locker, 2002). This
again brings us to the fact that explaining the procedure
as highlighted in the previous paragraph, gives patients a
sense of control and is useful in allaying their anxiety.
Study by Eli et al suggests that the level of patient’s
anxiety was affected by evaluation of the present dentist by
the patient and memories of anxiety from childhood and
also by the personality traits of the patient (Eli et al, 1997).
Some training centers have communication skills train-
ing programs for students in dentistry to teach students
micro-skills such as dealing with anxious patients. It has
been shown that communication skills training has an effect
on the knowledge and a substantial effect on the behavior
of the students (van der Molen et al, 2004).
Top tips
❑ Clear communication involves making simple and short
statements asking only one question at a time.
❑ Active/attentive listening is a key feature of good com-
munication. It involves making a good eye contact and
also by using non-verbal modes of communication
(head nodding).
❑ Avoid interrupting when the other person is talking.
❑ Ask questions to clarify what the person actually meant
when unclear.
❑ It is important to confirm that the person has under-
stood what the doctor had to say. ‘Have you understood/
Am I clear?’, ‘Do you have any questions?’
❑ Reassure, explain that the procedure can be stopped at
any time if the patient cannot tolerate it.
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 Section X – Appendices
Medications
Antidepressants
Antidepressants are drugs that relieve symptoms of depres-
sion. They were first developed in 1950s and have been used
regularly since then. There are almost 30 different kinds of
antidepressants which belong to the four major categories:
tricyclics, mono amine oxidase inhibitors (MAOIs), SSRIs
and serotonin noradrenaline reuptake inhibitors (SNRIs).
Antidepressants work by increasing the activity of certain
neurotransmitters mainly serotonin and noradrenaline.
Antidepressants are used to treat moderate to severe depres-
sive illness, severe anxiety and panic attacks, OCD, chronic
pain, eating disorders and PTSD.
The tricyclic antidepressants such as imipramine, ami-
triptyline, nortryptiline and dosulepin cause side effects
such as dry mouth, slight tremor, tachycardia, constipation,
sleepiness and weight gain. In addition to these anticho-
linergic side effects men may experience delayed ejaculation
and difficulty in getting or keeping an erection. Tricyclic
antidepressants are less commonly used as they are danger-
ous in overdose.
SSRIs are the commonly used first line treatment and
include drugs such as fluoxetine, sertraline, citalopram and
paroxetine. SSRIs are generally well tolerated and less harm-
ful in an overdose which make them the most popular. SNRIs
are very similar to SSRIs although venlafaxine should not
be used in patients with heart problem and needs monitoring
of blood pressure. MAOIs are rarely prescribed these days
as they cause dangerously high blood pressure on eating
food containing ‘tyramine’ known as ‘tyramine reaction’.
It is important to check for the dangerous drug interactions
before prescribing if a patient is on MAOIs. It is generally
best to taper off the dose of an antidepressant as stopping
it suddenly may cause withdrawal such as stomach upset,
anxiety, dizziness and flu-like symptoms. The current rec-
ommendation is that antidepressant should be continued
for at least 6 months after complete remission of symptoms.
If one has suffered from two or more episodes of depression
then treatment should be continued for at least 2 years.
Antipsychotics
Starting from the mid 1950s several medications were dis-
covered that reduce the symptoms of schizophrenia and
other psychotic disorders. They came to be known as ‘anti-
psychotic’ medications. These older drugs are called ‘typical’
or ‘first generation’ antipsychotics. They work by reducing
the action of dopamine in the brain (dopamine antagonist).
Some typical antipsychotics are chlorpromazine, haloperi-
dol, pimozide, trifluoperazine and sulpiride. Some of these
typical antipsychotics are available in long acting depot
injection form which can be administered once in 2 to 4
weeks for people who do not comply with oral medications.
e36
Appendix2.indd e36
The typical antipsychotics have more side effects than
atypicals. The side effects include stiffness and shakiness
as in Parkinson’s disease along with feeling sluggish and
slow in their thinking. Other side effects include uncom-
fortable restlessness (akathisia) and sexual side effects.
A long-term side effect is ‘tardive dyskinesia’—persistent
movements generally of the mouth and tongue which is
difficult to treat and very disabling.
Over the last 10 years, several newer medications have
been in use. They work on a different range of chemical
messengers in the brain including the serotonin system
(serotonin dopamine antagonists). These came to be known
as ‘atypical’ or ‘second generation antipsychotics’. These
atypical antipsychotics are less likely to cause parkinso-
nian side effects although they may cause weight gain and
problems with sexual functions. They may also help the
negative symptoms on which the older drugs have very
little effect. They also seem to have much less propensity
to cause ‘tardive dyskinesia’. The common side effects of
atypicals include weight gain, sexual side effects, glucose
intolerance and increased chance of developing Type 2
diabetes and sedation. The commonly used atypical antip-
sychotics include risperidone, olanzapine, quetiapine,
amisulpiride and clozapine. Risperidone is the only atypi-
cal antipsychotic which is available in the form of long
acting injection.
Clozapine is an atypical antipsychotic medication and
the only one that has shown to be more effective for peo-
ple who do not respond to other sorts of antipsychotics.
In addition to the side effects of the atypicals mentioned
above, clozapine also produces increased salivation. The
main drawback is that it can affect the bone marrow reduc-
ing the white cell count causing agranulocytosis which
can be fatal. For this reason, patients taking clozapine need
weekly full-blood count for the first 6 months, 2 weekly for
the next 6 months, and 4 weekly thereafter.
Most patients with schizophrenia need to take antipsy-
chotics for a long time. On stopping the treatment, symp-
toms of schizophrenia usually come back, if not immediately,
often within 6 months. It is advisable to reduce the dose of
the medication gradually, only in discussion with a psy-
chiatrist who will monitor for early signs of relapse.
Anti-manic agents
Medications used to treat mania include mood stabiliz-
ers such as lithium and valproate. Other medications used
to treat mania include antipsychotics and benzodiaz-
epines. Medications used to prevent the relapse of manic
episodes in manic depression (bipolar disorder), include
drugs such as lithium, valproate, carbamazepine and
lamotrigine.
Lithium has over the last 40 years been the most com-
monly used drug to prevent relapse. Lithium is a safe drug
when taken at the correct dose, however it has a narrow
11/6/2009 3:54:38 PM
 Appendix II – Mental Health and Its Relevance to Dentistry

therapeutic window (0.6 to 0.8 mmol/l) and becomes unsafe resistant severe depression, severe mania and catatonia
above this level in the blood. The common side effects (NICE, 2003). ECT is used more as a life saving treatment
include fine tremors, metallic taste in the mouth, tiredness, for quick resolution of very severe symptoms and is always
weight gain and underactive thyroid gland. Long-term treat- supplemented with a continuation of the most appropriate
ment with lithium can cause renal impairment. It is thus pharmacotherapy.
important to periodically check for serum lithium level,
thyroid functions and renal functions including creatinine Psychological (talking therapies)
clearance. Lithium is an ion and is excreted unchanged from
There are several types of ‘talking treatments’ also known
the kidneys. Drugs such as diuretics and NSAIDs can dan-
as ‘psychotherapy’. These are different ways of helping peo-
gerously increase the serum lithium levels and so it is very
ple to overcome stress, emotional problems, relationship
important to check for drug interactions before prescribing
problems and troublesome habits. The commonality in these
for a patient on lithium.
treatments is talking to another person and sometimes
Valproate and semi-sodium valproate are becoming
doing things together. Behavioral psychotherapy tries to
widely used treatment for mania and bipolar disorder.
change the behavioral patterns of the patients and helps
The common side effects of valproate include sleepi-
to overcome fears by spending more and more time in the
ness, dizziness, increased appetite and weight gain, skin
situation they fear. They are also given homework exercises
rashes and irregular periods. Very rare side effects include
and are asked to keep a diary to practise the new skills in
pancreatitis and liver failure. It is again very important
between the sessions. This type of behavioral psychother-
to check for drug interactions as valproate is a hepatic
apy is effective for panic, phobias, anxiety, OCD and vari-
enzyme inhibitor and reduces the metabolism of other
ous kinds of social and sexual difficulties. Results are seen
medications.
quite quickly. CBT aims at changing the thinking patterns.
Carbamazepine is usually used as a second line treat-
It emphasizes on how the thinking, behavior, emotions
ment for bipolar disorder. Unlike valproate, carbamazepine
and physiological symptoms are all related in a particular
is a hepatic enzyme inducer and increases the metabolism
instance and is influenced by the environment. It encour-
of other medications and thus reduces their efficacy.
ages a discussion on how we think and helps us to get rid
Interestingly it reduces its own level and needs bigger
of unhelpful ways of thinking. It focuses on the present
doses with longer treatment. Lamotrigine also helps to
and not on the past. CBT have achieved particular success
prevent mood swings particularly of severe depressive epi-
in the treatment of certain types of depression. Psychody-
sodes. It is however not used as a mono therapy for bipolar
namic psychotherapy focuses on the feelings one has about
disorder.
other people, family and those close to the individual. This
mode of treatment involves discussing the past experiences
Electroconvulsive therapy and how these may have led to the present situation and
affecting the individual’s life. It may involve a brief therapy
Electroconvulsive therapy (ECT) is a treatment used in psy-
for a specific difficulty or may be long standing with daily
chiatry for severe mental illnesses. It was originally devel-
sessions lasting for many years. Family therapy focuses
oped in the 1930s and was used widely during the 1950s
very clearly on the relationships, boundaries and commu-
and 1960s for a variety of conditions. Since then its use
nication styles in the family of the concerned individual.
was declined. ECT remains a controversial treatment, which
Marital therapy is for relationship problems in a marriage,
some people have strong feelings about. There are those
partnership or family. In all the above forms of therapy, the
who claim it can be a life saving procedure, while others
therapist may be a psychiatrist, psychologist or the mental
feel it should be banned. ECT is a way of causing someone
health professional who has had an in-depth training in
to have a seizure and it is this seizure that is needed for the
psychotherapy. These therapies are usually done under
treatment to work. The seizure is made to happen by pass-
supervision.
ing an electric current across the person’s brain in a care-
fully controlled way from a specially developed ECT device.
When to refer to a psychiatrist
The current can be administered to the whole brain when it
is called ‘bilateral ECT’ or just to the non-dominant hemi- As soon as you suspect a mental disorder and realize that
sphere called the ‘right unilateral ECT’. The seizure itself is the patient is not seeing a psychiatrist, it is good to think
very similar to the seizures that occur in people with gen- about referral. In general the earlier the mental illness is
eralized epilepsy, but it is caused on purpose in very con- detected the better the final outcome. Always try to reassure
trolled circumstances using generalized anesthesia and and encourage the patient to seek help for the mental
muscle relaxant, just like for a surgical operation. The aim health problems. Be non-judgmental and explain to the
of ECT is to cause a ‘generalized cerebral seizure’ between patient that treatment is available, and it is possible to
10 and 50 seconds long using the right dose of electricity. improve the quality of life with help from the mental
The current recommendation is to use ECT for treatment health services.

e37

Appendix2.indd e37 11/6/2009 3:54:38 PM

 Section X – Appendices
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