Dental Care for the Patient with Bipolar Disorder
David B. Clark, BSc, DDS, MSc (Oral Path), MRCDC •
Chronic mental illness and its treatment carry inherent risks for significant oral diseases. Given the shift in treatmentregimens from the traditional institutionally based approach to more community-focused alternatives, generaldental practitioners can expect to see and be asked to treat patients with various forms of psychiatric disorders. Onesuch group consists of patients with bipolar disorder (including type I bipolar disorder or manic-depressive disor-der). The purpose of this paper is to acquaint the dental practitioner with the psychopathological features of bipo-lar disorder and to highlight the oral health findings and dental management considerations for these patients.
Bipolar disorder is considered one of the most treatable forms of psychiatric illness once it has been diagnosedcorrectly. Through a combination of pharmacotherapy, psychotherapy and life-adjustment skills counselling, thesepatients are better able to understand and cope with the underlying mood swings that typify the condition and inturn to interact more positively and progressively within society as a whole. Both the disease itself and its variouspharmacologic management modalities exact a range of oral complications and side effects, with caries, peri-odontal disease and xerostomia being encountered most frequently. It is hoped that after reading this article thegeneral dental practitioner will feel more confident about providing dental care for patients with bipolar disorderand in turn to become a vital participant in the reintegration of these patients into society.
MeSH Key Words: bipolar disorder/drug therapy; bipolar disorder/complications; dental care for chronically ill
J Can Dent Assoc 2003; 69(1):20–4 This article has been peer reviewed. Bipolar disorder (including manic-depressive disor- or recreational pursuits. Affected individuals have difficulty der) is a psychiatric illness affecting approximately concentrating on simple tasks, become easily distracted and 1% to 2% of the general population,1–3 with no express feelings of hopelessness, worthlessness and guilt1,4 difference in prevalence among men and women. It is char- (Table 1).
acterized by variation in an individual's mood, thought The first manic episodes often occur in the late teens or content and behavioural pattern between extreme elation early twenties, and they tend to be of shorter duration than (mania) and depression. These cycles are often unpre- the depressive episodes. As the person becomes older, the dictable and of variable duration. Most patients display an intervals between episodes become shorter, with a concomi- extreme cycling of moods once every few years. However, tant increase in the duration of each manic or depressive some people, described as "rapid cyclers," experience mood swings at least 4 times per year, a situation more resistant to Both manic and depressive episodes result in significant conventional treatment.3 impairment in social and occupational functioning, which Manic episodes are characterized by hyperactivity, which can lead to marital instability, alienation from family and may involve excessive participation in multiple activities loss of employment.3 Poor insight and judgement often (e.g., sexual, occupational, religious or political). There is result in substance abuse, financial downfall and various often a demanding and increasing nature to these activities illegal activities. In fact, bipolar disorder exhibits one of the of which the individual is unaware. Days may pass with highest rates of associated substance abuse among all the little or no sleep. Speech is often rapid and loud, with major psychiatric illnesses, some studies showing up to a abrupt changes in ideas or topics.
60% lifetime prevalence of some form of substance abuse.6,7 Sadness, apathy, insomnia, loss of appetite, and It is well recognized that alcohol is abused by many decreased energy characterize the depressive phase. There is patients, but recent studies illustrate that abuse of other a loss of interest in daily activities, whether related to work substances, including marijuana, cocaine, LSD, heroin and January 2003, Vol. 69, No. 1 Journal of the Canadian Dental Association Dental Care for the Patient with Bipolar Disorder Table 1 Symptoms of bipolar disorder
Depressive symptoms
Excessive "high" or euphoric feelings Loss of appetite, weight loss or weight gain Obnoxious, provocative or intrusive behaviour Chronic pain or other persistent bodily symptoms not caused by Unrealistic beliefs in one's abilities and powers Increased energy, restlessness, racing thoughts, rapid speech Persistent sad or "empty" mood Difficulty in concentrating, remembering, making decisions Fatigue or sleep disturbances Denial that anything is wrong Table 2 Side effects of long-term use of
disturbances.4 Of greater significance is the fact that astrong familial pattern has been established. Patients with bipolar disorder are significantly more likely than patients Lethargy, fatigue, weakness, cognitive or with major depression to have parents and first-degree rela- memory impairment, fine tremors tives with mood disorders.11 Twin and adoption studies also Impaired tubular or glomerular functioning favour a strong genetic component to bipolar disorder: Lithium-induced hypothyroidism (5% to 35%), concordance rates are 60% to 80% for monozygotic twins nontoxic goitre (4% to 12%) and 14% to 23% for dyzygotic twins.2,11 T-wave depression on ECG (displacement ofintracellular potassium by lithium) There is no cure for bipolar disorder, but a 3-pronged Nausea, vomiting, diarrhea, abdominal pain,xerostomia treatment approach can be taken to the management of this illness: pharmacotherapy, psychotherapy and life- Benign leukocytosis (reversible) adjustment skills education. The pharmacotherapeutic Acneform eruptions, psoriasis phase is the one aspect of this treatment approach that Weight gain, altered glucose metabolism holds the greatest relevance for dental management proto- ECG = electrocardiography cols. Initial pharmacologic management involves theadministration of so-called mood stabilizers. Lithium other opiates, amphetamines and PCP (phencyclidine), is carbonate, an alkali metal, is one such mood stabilizer that becoming more prevalent.6 Recent research remains incon- was previously regarded as the treatment of choice for this clusive as to the effects of substance abuse on the overall illness.12,13 It is effective as an antimanic agent and also course of bipolar disorder. However, some studies have prevents recurrent depression and stabilizes mood swings.
shown a trend toward an increase in attempted suicides, The exact mechanism of action of lithium resides in its more noncompliance with medications, increased rates of capacity to alter membrane function, through the ease withwhich it is substituted for other cations involved in the cell hospital admission and nonresponsiveness to pharma- membrane-transport mechanism. Lithium enhances the cotherapeutic regimens.6,7 From the dental standpoint, an uptake of norepinephrine and serotonin into the synapto- awareness of the prevalence of drug abuse in patients with somes, thereby reducing their action. The onset of lithium bipolar disorder is important. For example, myocardial activity is slow, and up to 10 days may be required to ischemia and cardiac arrhythmias are a serious concern in achieve the desired effect, which can be attained in up to patients who are "high" on cocaine. Administration of 80% of patients if compliance is maintained. However, epinephrine-containing local anesthetics in the presence of lithium has a variety of side effects involving many systems cocaine intoxication will exacerbate the patient's response in the body12,14 (Table 2).
to sympathomimetic amines, which could result in myocar- In recent years, several new medications have been dial infarction, stroke or hypertensive crisis.8,9 developed for even more effective management of bipolar Individuals suffering from bipolar disorder are far more disorder,12 including anticonvulsants such as divalproex, a likely to commit suicide than patients in any other high- derivative of valproic acid. This particular medication is risk psychiatric or medical groups. Recent literature being used more frequently as a first-choice treatment for suggests that the rate of attempted suicides is 25% to 50%, mania because it is safer than lithium.12 Other medications and the overall completion rate is close to 15%.1,10 include antipsychotics such as risperidone and olanzapine, Although an exact cause for this condition has not been both of which display fewer side effects and less inter- identified, several contributing factors have been impli- ference with cognitive functioning than lithium.
cated, such as biologic abnormalities relating to brain Carbamazepine (an antiseizure drug) and verapamil (a anatomy or physiology and hormonal or biochemical calcium-channel blocker) have also been employed with Journal of the Canadian Dental Association January 2003, Vol. 69, No. 1 with bipolar disorder, thereby contributing in some degree Table 3 Dental management of the patient
to their psychological rehabilitation.16 The overall goal of with bipolar disorder
treatment planning must incorporate the maintenance of Consult with physician or psychiatrist oral health, comfort and function as well as the prevention Patient's current medication regimen and potential drug and control of specific oral disease (Table 3). Before
Degree of compliance with pharmacotherapy commencing any treatment, the dental practitioner should Current status and psychological profile consult with the patient's physician or psychiatrist to Undertake aggressive preventive education program confirm or update information about the current medica- Oral hygiene instruction tion regimen, degree of compliance, ability to provide Frequent recall appointments consent and overall psychological profile.17 The dental prac- Regular use of topical fluorides (e.g., dentifrices, gels in titioner should also be aware that depressed patients may be Dietary counselling uncooperative for even simple routine procedures.
Manage xerostomia and mucosal pathology During depressive episodes, many patients exhibit a Salivary substitutes and stimulants distinct decline in the level of oral hygiene, coupled with a Chlorhexidine mouth rinses rise in dental caries and periodontal disease, which often Regular examination of oral soft tissues progress to an unmanageable situation.18–20 Dental hygiene Use local anesthetic agents containing epinephrine judiciously: is neglected, and any existing prostheses may become ill- aspirate and inject slowly, and avoid use of epinephrine in retraction cords, hemostatic agents, etc.
fitting and may be discarded.21 Conversely, during manicperiods, overzealous use of oral health aids (such as tooth- Avoid or use reduced dosages of sedative and hypnotic agentsand narcotic analgesics brushes and floss) may be associated with a correspondingincrease in the incidence and severity of cervical abrasion, as increasing frequency in patients with bipolar disorder in well as occasional mucosal or gingival lacerations.22,23 whom the response to lithium has been inadequate.5,12 Unfortunately, medical pharmacotherapy for bipolar disor- Antidepressant medications such as tricyclic antidepressants der can result in moderate to severe xerostomia, which and selective serotonin reuptake inhibitors may be added to further compounds the severity of any dental disease.24–26 the therapeutic regimen in some instances to assist in the With reduced salivary flow there is a rapid increase in the management of the depressive phase.15 Patients with bipo- degree of dental deterioration, mucosal dryness and dyspha- lar disorder who have demonstrated medication compliance gia. Patients often experience a sharp increase in rampant can be maintained indefinitely on these therapeutic regi- cervical caries not only because of the anticholinergic effects mens with few harmful side effects, which allows them to of lithium and other psychotropic medications, but also lead relatively productive and active lives. Consequently, because they use candies or sweetened beverages to provide the community dental practitioner will see such individuals some form of oral lubrication.5,15 High caffeine intake and for dental treatment and must consider the special prob- heavy smoking exacerbate the drying effects of various lems and concerns related to this particular illness.
medications.27 Other consequences of hyposalivation can Electroconvulsive therapy (ECT) may be indicated for include an increased incidence of yeast infections patients with severe depressive episodes that are refractory (Candida),26 fissuring of the corners of the mouth to medication.15 With ECT, a central nervous system (perlèche)28 and lips, and difficulty in chewing, speaking seizure is created by means of an electric current; the seizure and swallowing.28 is thought to accentuate the responsiveness of neuronal There have been numerous reports of the oral side effects membranes to norepinephrine and serotonin. It is impor- of long-term lithium therapy, which can have some impor- tant for the anesthetist or dental consultant to assess the tance to dental management. Lichenoid stomatitis has been patient's dentition before ECT to rule out any loose or reported as an adverse reaction to lithium carbonate14,29 and broken teeth that could be aspirated during the treat- is thought to represent a response to alterations in ments.15 As well, partial or complete dentures must also be immunoregulation induced by the lithium therapy.
identified. A bite block is generally placed between the teeth Nonspecific stomatitis in association with lithium therapy by the anesthetist to protect both the teeth and the tongue has also been reported.30 Other patients have reported a from the clenching that occurs upon stimulation of the metallic taste sensation while taking lithium therapy.8 masseter muscles.
As in the pharmacotherapeutic management of any disease, there is a wide range of interactions between the Dental Therapeutic Considerations
drugs used in managing bipolar disorder and those used by Through encouragement, motivation and education dental practitioners. Concomitant administration of about improving health, the dental practitioner can lithium and metronidazole or tetracycline may cause renal enhance the sense of identity and self-esteem for patients retention of lithium, which could lead to toxic effects.5 January 2003, Vol. 69, No. 1 Journal of the Canadian Dental Association Dental Care for the Patient with Bipolar Disorder Nonsteroidal anti-inflammatory drugs such as ibuprofen are reported to increase plasma lithium levels by as much as Cases of bipolar disorder represent a significant propor- 60%, so more frequent monitoring of plasma lithium levels tion of patients with mental illness. The general dental may be needed.5,8 practitioner must be prepared to consider the special prob- Preventive dental education for these patients and their lems and features unique to this type of psychiatric disease.
families continues to be the mainstay for not only institu- With a thorough medical history (often generated in tional but also community-based dental treatment consultation with the physician or psychiatrist), appropri- programs. Studies have shown that the longer the period of ate examination and knowledge of the diagnosis, most hospitalization for psychiatric illness, the greater the inci- dental services can be provided to clients with bipolar disor- dence of dental caries, periodontitis and subsequent tooth der, often in association with an aggressive program of loss; conversely, outpatients have in general demonstrated preventive dental education. The dentist's ability to better oral health than inpatients.2,18,31,32 Reinforcement of contribute to the increased feelings of self-worth and over- both tooth-brushing and flossing techniques are required to all psychotherapeutic management of these individuals can maintain and enhance plaque removal. The use of a be a rewarding experience and demonstrates the harmo- chlorhexidine gluconate mouth rinse can be effective in nious interaction that can be achieved in the overall reducing the severity of gingivitis. However, the secondary medical and dental management of patients with bipolar effects of staining of teeth reported in the literature must be reviewed with the patient.33 A protocol for dry mouthmanagement may be required.28,34 Commercially available Acknowledgment: The author gratefully acknowledges Ms. Andrea
saliva substitutes, either in liquid form (Mouth Kote, Johnston, Pharmacy Services, Whitby Mental Health Centre, for herassistance in the preparation of this manuscript. Parnell, Mississauga, Ont.) or gel form (Oral Balance, Dr. Clark is head of dental services at the Whitby Mental Health
Laclede, Inc., Rancho Dominguez, Calif.), provide tempo- Centre in Whitby, Ontario. rary relief from symptoms in both dentate and edentulous Correspondence to: Dr. David B. Clark, Whitby Mental Health
individuals wearing complete dentures. Avoidance of both Centre, 700 Gordon St., Whitby, ON L1N 5S9. E-mail: caffeinated and alcoholic beverages reduces the intensity of xerostomia. Sugar-free candies and chewing gum offer The author has no declared financial interests in any company manu-facturing the types of products mentioned in this article. some stimulus to increase salivary flow. Taking frequent sipsof water throughout the day also relieves symptoms.
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Acne Pathway (January 2015) Key Points:  Encourage patient self-care and check for aggravating factors.  Mild and moderate acne with low risk of scarring, prescribe a single topical treatment (either topical retinoid or benzoyl peroxide. Combined treatment is rarely necessary). For mild acne, benzoyl peroxide based treatments are available over the counter (OTC) from local community pharmacies.