Chapter 5

Managing the Patient With Mental Illness

Aim

The aim of this chapter is to increase awareness and understanding of mental illness through three common conditions – schizophrenia, depression and dementia.

Outcome

After reading this chapter you should have an understanding of three common causes of mental illness – schizophrenia, depression and dementia – their signs and symptoms, their effects on oral health, and how to manage the oral care of people with these conditions. This will also give you a basic understanding of the management of any patient who develops mental illness.

Introduction

Mental illness is defined as a disorder of the brain that results in a disruption in a person’s thinking, feeling/mood, ability to relate to others and the ability to work. Mental illness is common. It has been estimated that around 20% of adults will suffer from a clinically diagnosable mental illness in a given year, but less than half of them will suffer symptoms severe enough to disrupt their daily functioning. Mental illness can have a huge impact on the ability to carry out daily living activities, including accessing and coping with dental services and maintaining daily oral hygiene. Consequently, mental illness can impact on oral health. Oral conditions may also be presenting features of mental illness, particularly of depression. They include atypical facial pain, atypical odontalgia, burning mouth syndrome and disordered taste and salivation. Organic causes should always be considered first in any differential diagnosis.

1. Schizophrenia

Schizophrenia ranks amongst the top 10 causes of disability. It is a form of mental illness in which mental function is impaired to the degree that it interferes with the ability to meet the demands of everyday life and to maintain contact with reality. Insight is diminished or lost completely. Some people only have one episode of schizophrenia during a lifetime. Others have many episodes, but lead relatively normal lives during the interim periods. The individual with a recurring or continuous pattern of illness often does not fully recover normal functioning and requires long-term medication to manage the symptoms.

Cause

There is no known single cause. It is likely that the disorder is associated with an imbalance of the complex chemical systems of the brain. There is an underlying genetic vulnerability to developing it. For example, the child of a parent with schizophrenia has a 1 in 10 chance of developing it compared with the general population risk of 1 in 100. Even so, certain environmental factors are needed before the disorder manifests. These factors include family relationships, life events (both good and bad) and infection.

Signs and Symptoms

The world of people with schizophrenia is one of:

• Disordered perceptions of reality.

• Hallucinations and illusions – hallucinations may be auditory, visual, tactile, gustatory or olfactory. Hearing voices that other people do not hear is commonest. The voices may describe the person’s activities, carry on a conversation, warn of impending dangers or issue orders.

• Delusions – these may be of persecution, false or irrational beliefs (e.g. of being cheated, harassed, poisoned or conspired against), or delusions of grandeur. They can be bizarre (e.g. believing that someone is controlling their behaviour with magnetic waves, or that their thoughts are being broadcast aloud).

• Disordered thinking – resulting in the inability to concentrate, being easily distracted, unable to focus attention, and unable to sort out what is and is not relevant to a situation. It can result in thought disorder.

• Blunted or flat emotional expression – such that a person may speak in a monotone voice, have diminished facial expression, and appear apathetic and withdrawn.

Management

The mainstay of treatment is the use of antipsychotic medication. Most people show dramatic improvement with these drugs. Their side-effects include:

• drowsiness or restlessness

• muscle spasms

• xerostomia – leading to increased risk of caries, periodontal disease, denture problems and oral infection

• tardive dyskinesia – a disorder characterised by involuntary movements most often affecting the jaws, lips and tongue causing involuntary movement of the tongue and facial grimacing that can lead to difficulties in the delivery of dental treatment and in wearing dentures

• agranulocytosis – the white blood count should be regularly monitored. Repeated dental infections could indicate a low white blood cell count.

Psychosocial treatments such as rehabilitation, individual psychotherapy, and family education and self-help groups are also used in the management of schizophrenia.

Nicotine

The most common form of substance misuse in people with schizophrenia (approximately 75–90%) is nicotine dependence through smoking. Whilst people smoke to self-mediate their symptoms, nicotine interferes with the response to antipsychotic drugs. Several studies have found that people with schizophrenia who smoke need higher doses of antipsychotic drugs. Heavy smoking has a detrimental effect on oral health.

Violence

Despite the common stereotype linking schizophrenia and violence, studies indicate that most people with schizophrenia are not prone to violence. The specific subgroups include:

• people with a record of criminal violence before becoming ill

• people with substance misuse or alcohol problems

• people with paranoid and psychotic symptoms.

Oral Health

People with schizophrenia have greater risk of oral diseases and have greater oral treatment needs. Generally there is a higher incidence of caries and worse periodontal conditions than in the general population. This is the result of a complex interrelationship of socioeconomic factors, illness, its treatment, deterioration in ability to self-care, habits such as poor diet and smoking, dental attendance, and barriers to access to oral care.

Dental Management

It is unlikely that an individual in an acute episode of their illness will seek dental care, and the majority of people with schizophrenia can be safely treated in mainstream dental practice. People with chronically poorly controlled, or uncontrolled, schizophrenia require referral to a specialist dental service.

Challenges that this group of people may present to the dental team include:

• Communication – this can be difficult because of associated disordered thinking or because of auditory hallucinations. In the latter case, it is prudent to check if the patient has heard what you said. If their voices are talking to them, you will not have been heard.

• Cooperation – this may vary from patient to patient or from visit to visit for the same person. Gentle persuasion is worth trying but the individual’s wishes need to be respected. If a patient is openly uncooperative or shows signs of aggression it is best to curtail the appointment as politely as possible.

• Compliance – little interest and/or ability to maintain oral hygiene is part of the condition when it is poorly controlled or uncontrolled. This can be frustrating to the dental team but it needs to be remembered that this is a feature of the illness.

• Delusions – it is recognised that some people with schizophrenia have believed that they receive radio transmissions from amalgam fillings. If a non-metallic restorative material can be used, this is a safer option. Where this is not optimal, inform the individual what you will be doing and check out that it is acceptable.

• Personal priorities – people with schizophrenia often know exactly what they want, and they want it now! Thus it might be necessary to restore a tooth first, even though this might not be optimal treatment planning, in order to engage the patient in other aspects of oral health/hygiene.

• Perception – it is prudent to ensure that you are always chaperoned and to keep detailed records as the individual with schizophrenia may have a different perception of an event from the reality.

An understanding dental team, aware of the issues associated with schizophrenia, with good patient management skills and an empathic attitude, may help to motivate a patient with schizophrenia towards good oral health.

2. Endogenous Depression

Endogenous depression results from a chemical imbalance in the brain, (e.g. a deficiency in the mood-e/>

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