Section I: Clinical Scenario and Dental Considerations

Clinical Scenario

A 47‐year‐old female attends your dental clinic asking for replacement of her lost teeth. The appearance of her mouth is contributing to her low self‐esteem. She no longer smiles and avoids leaving the house. She appears unkempt and is extremely thin.

Medical History

  • Depression, diagnosed 22 years ago
  • Asthma (controlled)
  • Underweight (BMI = 16.3 kg/m2)


  • Fluoxetine
  • Fluticasone/salmeterol
  • Salbutamol

Dental History

  • Irregular dental attender; last visit was 4 years ago
  • Reports consuming chocolates, pastries and soft drinks several times a day but does not have regular meals
  • Brushes her teeth intermittently; often forgets

Social History

  • Single, lives alone, no next of kin
  • No contact telephone number
  • Occasional informal jobs helping her neighbours
  • Receives disability pension due to depression
  • Tobacco: cigarettes 2–4/week
  • Alcohol: 14 units per week (binge drinking)
  • Other drugs: cocaine base paste (cocaine, tobacco, cannabis mix) with tobacco in a pipe once a week (5 years); previously used to consume cannabis

Oral Examination

  • Vertical dimension loss
  • Palatine torus
  • Dry tongue/mouth
  • Generalised soft and hard deposits
  • Generalised periodontitis
  • Partially edentate (Figure 15.2.1)
  • Retained roots: #17, #24, #27 and #41(Figure 15.2.2)
  • Extensive caries: #15, #23, #34, #32, #31, #43 and #44 (Figure 15.2.3)
Photo depicts partially edentate, deep overbite, multiple carious teeth (S).

Figure 15.2.1 Partially edentate, deep overbite, multiple carious teeth.

Photo depicts maxillary dentition: retained roots number 17, number 24 and number 27; palatine torus (S).

Figure 15.2.2 Maxillary dentition: retained roots #17, #24 and #27; palatine torus.

Photo depicts mandibular dentition: retained root number 41; caries number 34, number 32, number 31, number 43 and number 44 (S).

Figure 15.2.3 Mandibular dentition: retained root #41; caries in #34, #32, #31, #43 and #44.

Radiological Examination

  • Full‐mouth periapical radiographs undertaken (Figure 15.2.4)
  • #17, #24 and #27: retained roots with apical lesions
  • #41: retained root
  • #23: deep distal caries with pulpal involvement; mesial caries
  • #31 and #32: extensive cervical caries; extensive horizontal bone loss
  • Further dental caries: #15 deep cervical caries, #34 buccal and distal caries, #43 deep mesial caries, #44 mesial caries, #42 missing; generalised bone loss (~60–80%)

Structured Learning

  1. What could be the connection between the patient’s depression and her low body mass index (BMI)?
    • Depression and eating disorders have a bidirectional relationship
    • An additional diagnosis of anorexia nervosa should be considered
    • This will have a further impact on the social, medical and dental risk factors when planning care
  2. What factors have contributed to the poor dental status of this patient?
    • Self‐neglect
    • Irregular dental attender
    • Cariogenic diet
    • Fluoxetine can cause a dry mouth and hence increase the dental caries risk further
    • Cocaine use can also result in a dry mouth
    • Binge drinking can lead to further oral neglect
    • Asthma medication oral side‐effects (see Chapter 9.2)
  3. The patient is convinced that improving her dental appearance will help her find a job and hence cure her depression. Is she correct?
    • Loss of teeth and unattractive smile can have an impact on the patient’s psychological state, increasing low self‐esteem, withdrawal and isolation
      Photo depicts full-mouth periapical radiographs demonstrating multiple retained roots and carious teeth (M/L).

      Figure 15.2.4 Full‐mouth periapical radiographs demonstrating multiple retained roots and carious teeth.

    • Although improving the appearance of the teeth may be a positive action, it will not cure her depression
    • The patient’s expectations need to be realistic
  4. What factors do you need to consider in your risk assessment for the management of this patient?
    • Social
      • Irregular attender, poor compliance and tolerance
      • Associated habits (see Chapters 15.4 and 15.5)
      • No telephone contact number
      • No escort or next of kin
      • Financial constraints (irregular income)
    • Medical
      • Asthma (consider patient’s triggers) (see Chapter 9.2)
      • Low BMI; poor diet (risk of deficiencies/anaemia/delayed healing)
      • Potential increased bleeding risk (side‐effect from fluoxetine)
    • Dental
      • Deep overbite
      • Reduced denture retention (mandibular ridge resorbed posteriorly; palatine torus; dry mouth)
      • Poor dental status
      • Managing expectations
  5. The patient wants dental treatment to commence immediately. What would you need to ensure in relation to her depression?
    • Ideally, a course of dental treatment should be scheduled when the patient is actively accessing support for their depression
    • This will increase the likelihood of a successful dental treatment outcome
    • Some simple dental procedures (e.g. retained root extractions) can be provided to stimulate the patient and help change attitudes and habits
  6. Given that the prognosis of her remaining teeth is poor, you advise a dental clearance followed by provision of complete denture. What would be the challenges in relation to construction of a denture?
    • Construction of an immediate denture is not advisable due to the loss of multiple teeth and gross caries in the remaining teeth
    • Healing after the dental extractions may be delayed
    • Multiple visits required to construct the denture
    • Retention may be reduced in relation to xerostomia and the presence of a palatine torus
  7. The patient fails to attend the dental appointment booked to commence dental extractions. What would you do?
    • This may be a safeguarding concern, particularly if the patient reports suicidal ideation
    • As the patient has no next of kin/family or telephone number, contact the doctor to register your concern

General Dental Considerations

Oral Findings

  • Oral neglect
  • Xerostomia
  • Caries
  • Periodontal disease (including necrotising ulcerative gingivitis/periodontitis in severe cases of depression)
  • Bruxism and attrition
  • Sialadenitis
  • Cheilitis
  • Dysphagia
  • Facial dyskinesia caused by antidepressants
  • Oral lichen planus
  • Recurrent aphthous stomatitis
  • Atypical facial pain
  • Burning mouth syndrome
  • Temporomandibular pain dysfunction syndrome
  • People with depression are 20–30% more likely to be edentulous
  • Depression is closely linked to unhealthy habits (tobacco, alcohol and drug consumption, and poor eating habits); oral manifestations linked to these, including the risk of oral cancer, need to be considered

Dental Management

  • Referral for psychological diagnosis and support should be considered in a patient where depression is suspected
  • If there is immediate concern regarding the patient’s well‐being (e.g. suicidal ideation), emergency services should be contacted
  • A sympathetic, non‐judgemental approach is essential when planning and providing care
  • Goals are difficult to maintain in the long term and recurrences are frequent. Treatment goals may need to be reassessed depending on the patient’s level of engagement and compliance (Table 15.2.1)

Section II: Background Information and Guidelines


Depression is a common mental disorder affecting 320 million people worldwide. It is characterised by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities (WHO). It can lead to a variety of emotional and physical problems, and can dramatically affect a person’s ability to function and live a rewarding life. The lifetime risk of developing depression is 10% in the general population, affecting more women than men (2:1). It is a major global cause of disability, and is the most common disorder contributing to suicide.

Table 15.2.1 Considerations for dental management.

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Risk assessment
  • The patient may appear withdrawn, difficult or aggressive
  • Safeguarding concerns if there is associated self‐harm ideation
Criteria for referral
  • Dentists should be able to manage the vast majority of patients with mild depression
  • Uncontrolled depression (e.g. suicidal ideation) requires referral
  • Institutionalised patients may require a home visit

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Nov 6, 2022 | Posted by in Implantology | Comments Off on Depression

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