Effect of Psychiatric Disorders on Oral Health Status in Central Region of Saudi Arabia – A Clinical Study.
1. Abdulrahman A. Al- Atram e-mail: [email protected] Professor, Department of Psychiatry,
College of Medicine,Majmaah University, Kingdom of Saudi Arabia
2. SaleemFaiz Shaikh e-mail: [email protected]
Faculty, Department of Maxillofacial surgery & Diagnostic Sciences College of Dentistry, Majmaah University
Kingdom of Saudi Arabia ORCID - 0000-0002-7836-0917
3. Mohamed HelmySalama e-mail: [email protected]
Assistant professor of periodontology, College of Dentistry, Majmaah University, KSA. - Assistant professor of periodontology, College of
Dentistry, Al-Azhar University, Cairo, Egypt ORCID - 0000-0002-0067-5564
Corresponding author
Corresponding Author Dr. SaleemFaiz Shaikh
College of Dentistry, Majmaah University, Semnan,
City – Alzulfi Province - Riyadh Kingdom of Saudi Arabia.
e-mail: [email protected] Phone number: +966535743847
Abstract:
Background: Mental disorders have high comorbidity which includes oral disorders.
Many studies have been conducted to evaluate the oral health of psychiatric in patients however the data regarding the oral health status of psychiatric outpatients is scanty.
Objective: To determine the effect of psychiatric disorders on oral health status in central region of Saudi Arabia
Methods: A case-control study of 100 subjects in each group was conducted;
Clinical parameters like gingival index, Plaque index, Probing pocket depth, Clinical
attachment loss& Decayed missing filled teeth were assessed. The data was statistically analyzedby using two tailed ‘t’ test.
Results: Highly statistical significant differences were seen between the scores of case and control groups in all the periodontal variables measured. The mean DMFT score was more in the case group. All the variables (DMFT) had statistically significant difference among the case and control group except for filled teeth, which were more in the control group
Conclusion: Poor oral health status seen among the psychiatric outpatients, makes it an important factor in public health and focus on the physical health of the psychiatric illness should include consideration of oral health. Dentists should be motivated towards working and serving psychiatric patients.
Key words: caries, periodontal diseases, mental disorders, plaque index.
Introduction:Mental health is one of the important components of health, and good mental health is prerequisite for the maintenance of good physical health. People who are mentally ill suffer not only from their psychiatric conditions but also from deficits in the physical and psychosocial domains of their health.1 Oral health is an integral part of general health, evidence indicates that there is a psychosocial contribution to oral diseases; therefore oral health should no longer be separated from mental health.
However mental disorders are difficult to treat and are complex as they show high comorbidity with long term costs on the individual family and society this makes them to neglect other aspects of health, specially maintenance of oral health[1,2].
Dental caries and periodontal disease are the two most common diseases that affect oral health. [3-5] Up to 90% of the world, population could be affected with periodontal diseases demonstrating the high rates of infection. If left untreated, it can lead to progressive loss of the alveolar bone around the teeth, resulting in loosening and loss of teeth. Psychosocial factors and certain medical conditions such as diabetes and infection with human immunodeficiency virus were identified as risk factors for poor oral hygiene. [6-10]
There is evidence supporting the association of mental disorders with physiological and behavioral precursors of caries and periodontal disease which suggest that such a link is possible. First, the physiological responses associated with mental disorders may reduce salivary flow due to sympathetic stimulation.[11,12]
Antidepressant and anxiolytic medication have been associated with reduced salivary flow and poorer oral hygiene; reduced salivary flow rate is related to a lower buffering action on acid producing cariogenic bacteria. [13] Also, these physiological changes involve abnormal immune responses involved in the pathogenesis of periodontal disease, as the alteration of the hypothalamic–pituitary–adrenal axis (HPA) exerts a pro-inflammatory or anti-inflammatory effect on tissues. Increased inflammatory responses stimulate bone resorption, whereas immunological deficiencies lead to lowering of host responses and further bacterial colonization.
[14,15]
Second, some behavioral changes associated with depression and anxiety, such
disease as well as increasing the risk of dental caries. [16] The latter is because of less exposure to fluoride toothpaste. Smoking is more common in people with mental disorders and could influence caries risk via changes in salivary buffer capacity.
Smoking has also been related with periodontal disease because it suppresses the immune response to oral infections. [17,18] Furthermore, people who are depressed or anxious consume more sweets and sugary snacks increasing their risk for dental caries. Moreover, people with mental disorders have poor adherence to treatment and attend dentists irregularly.Inadequate dental care could also be due to ignorance, fear, stigmas or negative attitude by the professionals. [19]
In the past two decades, it has been reported that the consequence of oral health whether from mental illness or other causes, has an effect on general health. It results in a range of medical conditions including cardiovascular diseases, type 2 diabetes, adverse pregnancy outcome, osteoporosis, aspiration pneumonia and rheumatoid arthritis. Current evidence suggests that improved oral health should be encouraged as part of the healthy lifestyle message to reduce the burden of chronic disease. [20]
Several studies have been done to access the oral health among ill-hospitalized psychiatric patients. They have reported poor oral health among hospitalized patient with psychiatric illness compared to general population. [21]In spite of the previous studies, there is lack of quantitative data on this hypothesis in thecentral region of Saudi Arabia; hence, this study was conducted to determine the effect of psychiatric disorders on oral health status in central region of Saudi Arabia.
Materials & Methods
:
This study was designed as a case control study with convenience sampling method. The study was approved by ethical committee of Majmaah University KSA [ref – 65/12451]and necessary permission was takenfromThe King Khalid Hospital of Majmaah and The Zulfi general hospital KSA.Itwas conducted from December 2018 to February 2019.The case group consisted of consisted of 100 chronic psychiatric patients above 18years who visited outpatient psychiatric clinic, the inclusion criteria was non-hospitalized patients who were co- operative for intra-oral examination with minimum 20 teeth excluding third molars.
Patients suffering from other systemic disorders other than psychiatric illness, patients suffering from other chronic oral diseases like malignant tumors and patients on cancer chemotherapy, patients with the presence of severe crowding or anatomical variations in dentition, pregnant and lactating females and who have received recent treatment with anti-inflammatory drugs, antibiotics, steroids, hormonal replacement therapy, or periodontal therapy in past three months were excluded from the study.
Control group consisted of equal number of age matched volunteers without any present or previous history of psychiatricillness. All the inclusion criteria and the exclusion criteria were same as the case group except for absence of psychiatric illness.
All the subjects from both groups were subjected to oral examination, which was carried out by twoexperienced examiners.Clinical parameters like gingival index [GI], Plaque index [PI], Probing pocket depth [PPD], Clinical attachment loss [CAL]&Decayed missing filled teeth [DMFT] were assessed for all subjects. The
results will be statistically analyzed to reveal the magnitude of difference between the two groups.Statistical calculations were performed using SPSS, version 23 for Windows (SPSS Inc, Chicago, IL, USA). Results are reported as mean ± standard deviation frequencies. Significance level was set at p < 0.05.
Results:The mean age of the subjects in case group was 37.2 and in the control group was 32.6. The case group consisted of 43 male subjects and 57 female whereas the control group had 50 male and 50 female subjects.
Periodontal status of both the groups was assessed, all the subjects suffered from some degree of gingivitis ranging from mild to severe. The findings of the various indices used are given in table 1. Highly statistical significant differences were seen between the scores of case and control groups in all the variables measured like gingival index [GI], Plaque index [PI], Probing pocket depth [PPD], Clinical attachment loss [CAL].
The caries experience of both groups was assessed using DMFT index. As seen in table 2, higher scores were seen in decayed filled and missing teeth in the case group, the overall mean DMFT score was more in the case group. All the variables had statistically significant difference among the case and control group except for filled teeth, which were more in the control group but not significantly more.
Discussion:Mental health is considered to be one of the fundamental components of health, currently 10% of the global load of diseases is due to psychiatric disorders and this is expected to increase to 15% by 2020. [20,21]Psychiatric disorders are associated with various other comorbid conditions. Oral health forms an integral part of health and affects all aspects of life, like personal, social and psychological. Many studies have been conducted to evaluate the oral health status of patients with psychiatric disorders. In our study as well as in many previous studies psychiatric patients or any patient with special needs have poor oral hygiene indicators, however psychiatric patients are at a greater disadvantage because they are unable to perceive their oral health related problems, they are also not motivated to maintain oral health and lack knowledge/skills to manage their oral health. Psychiatric patients are known to suffer from negative symptoms such as apathy and loss of drive, which might impede self-care, contributing to neglect of oral hygiene and subsequently resulting in deteriorated oral health. [24] On the flipside psychiatric patients often receive less or no dental care because they are treated with fear or social stigma by their relatives and care providers. They are taken to dental treatment only when they have pain or emergency and not for routine treatment.
Our study was done on the outpatients visiting the psychiatric clinic, even though their mental illness was mild or moderate; their periodontal parameters indicated that these patients had a significantly higher score as compared to the control group in all the four parameters measured (GI, PI, PPD, CAL). These findings were consistent with many of the previous studies done in other parts of the world.
[15, 20, 21, 25, 26]The poor periodontal indicators seen in such patients are due to the
gross neglect of oral hygiene and also some studies have reported certain psychiatric conditions like depression enhance the production of pro-inflammatory cytokines like interleukin (IL) -6. [27]
We also evaluated the dental caries experience of the case group using DMFT index. Our results indicate a significantly higher mean DMFT score as compared to the controls which is consistent with most of the previous studies. The DMFT mean for cases in our study was 4.6. This was comparable with most of the studies mentioned earlier except for some studies which reported a rate as low as 2.10, but this can be explained by the presence of higher concentration of fluoride in the water.
[28]Our study also reported a higher rate of decayed and missing teeth as compared to filled teeth which was consistent with some studies. [29] In contrast, Lewis et al found a similar level of decayed teeth, fewer filled teeth and more missing teeth between mental health patients and controls. [30] Filled teeth are seen less in the psychiatric patients due to lack of access to dental care.
Poor oral health status seen among the psychiatric outpatients in our study is less marked than with people who are hospitalized for severe mental illness. Our study did not focus on many factors such as type, severity and duration of mental illness or the accessibility of dental care, which could be the limitations of this study.
However the greater prevalence of common psychiatric disorders makes it an important factor in public health and people with psychiatric disorder should be considered as a disadvantage group who are not able to maintain their oral health and focus on the physical health of the psychiatric illness should include consideration of oral health. Dentists should be motivated towards working in mental hospitals and serving psychiatric patients.
Poor oral health among the study population reveals the inadequacy of both preventive programs and specialized professional services. Specific preventive dental program should be incorporated as an integral part along with psychiatric treatment and care. On the other hand, dental care providers should be aware of the role that psychological problems play in the origin and maintenance of oral complaints. Minor reforms in hospital administration could improve the oral health of patients in psychiatric hospitals. Better salaries and other incentives should be developed for those dentists who are willing to work in mental hospitals and serving psychiatric patients.
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Table 1: Periodontal Parameters:
Variable
Case group [Mean with
SD]
Control Group
[Mean with SD] ‘t’ ‘df’ P Value
[2 tailed ‘t’ test]
GI 1.950±.187 0.194±.296 15.814 15.814 <0.001 PI 2.038±.231 0.141±.095 23.987 11.960 <0.001 PPD 3.083±.720 1.261±.549 6.359 16.820 <0.001
CAL 0.944±.705 0.205±.185 3.206 10.236 .009
Table 2: DMFT Parameters:
Variable
Case group [Mean with
SD]
Control Group [Mean with
SD]
‘t’ ‘df’
P Value [2 tailed ‘t’
test]
D 3±2.10 0.8±1.13 2.905 13.815 .012
M 1.3±.948 0.2±.421 3.351 12.422 .006
F 0.3±.674 0.7±.823 -1.188 17.334 .251
DMFT 4.6±2.63 1.7±1.33 3.105 13.354 .008
