Professional Documents
Culture Documents
First and foremost I want to thank my advisor Dr Horia Coman. It has been an honor
to be his student. I appreciate all his contributions of time, ideas, and funding to make my
experience productive and stimulating. He helped me overcome all the problems encountered
in different parts of the thesis.
I would like to thank my family for all their love, encouragement and support,
without which this thesis wouldnt have been possible. I am indebted to my father Dr Edward
Ahenkorah and my mother for their care and love. They spare no effort to provide the best
possible environment for me to grow up and attend medical school. They have never
complained in spite all the hardship in their life.
My time at UMF Cluj-Napoca was made enjoyable in large part to my many friends
that became part of my life. I am grateful for time spent with my friends: Suffee Yusuf and
Dustagheer Azhar with whom it had been a pleasure for my medical journey in Romania.
Special thanks to my beloved Carmen Gisca without whom this project would not have been
a success.
IULIU HATIEGANU
JULY 2013
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CONTENTS
Introduction...4
THEORETICAL PART...5
Chapter I
Chapter II
Chapter III
PRACTICAL PART....41
Chapter 3. Results...................................................................49
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3.2 Clinical oral examination of patients 54
3.3 The relation between the oral health and mental illness..67
Chapter 4. Discussion................................................................70
Chapter 5. Conclusion...............................................................72
Bibliography..............................................................................76
Introduction
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A comprehensive discussion of oral health care for persons with mental illness in an
institutional setting is very challenging due to the variability of population served by mental
health. Oral health contributes to general health, self esteem and quality of life and although
oral health may have a low priority in the context of mental illness the impact of mental
illness and its treatment on oral health must be addressed.
People with severe mental illness are over three times more likely to lose their teeth
because of poor oral health. Recent research shows that psychiatric patients have not shared
in recent improvement in dental health and the researcher have called for free dental care for
people with severe mental illness.
This thesis examine the complex relation between oral health and mental illness and
analyse data between patients suffering from mental illness and treatment offered to them.
Data collected was also analysis in respect of different methodology to establish relationship
between mental illness and oral health.
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THEORETICAL
PART
CHAPTER I
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Dental disease and psychiatric illness are among the most prevalent health
problems in the Western world. While the dental needs of mentally ill people are similar in
type to those in the general population [ 1] there is some evidence that patients suffering from
mental illness are more vulnerable to dental neglect and poor oral health [ 2]; [3]. [4] Reports
that physical health problems are more common in psychiatric patients. They seem to be
poorly recognised by psychiatrists, and oral health is no exception [ 5]. Oral health is an
important aspect of quality of life which affects eating, comfort, speech, appearance and
social acceptance [6].
The two diseases which have a major impact on the oral cavity are dental caries
(tooth decay) and periodontal disease (gum disease). Dental caries is an infective process,
which may potentially destroy all exposed tooth surfaces. It is caused by acid produced by
micro-organisms which colonise dental plaque, the soft layer which accumulates on the tooth
surface. Dental plaque is also a key determinant of periodontal disease. Daily removal of
plaque by tooth-brushing, particularly with toothpaste containing fluoride, plays an important
part in maintaining oral health.
Routine dental health care for psychiatric patients was previously provided
within many of the large institutions. Since the introduction of community care, patients have
increasingly been given responsibility for arranging their own dental care, usually with a
general dental practitioner. The move towards independence means that patients need a
greater understanding of the potential risks of dental disease. This thesis aims to raise
awareness of oral health tissues in psychiatric patients and to promote better dental care for
the mentally ill. Even those without natural teeth will need a range of dental services. We feel
that there is a duty of care to prevent deterioration of dental health in this vulnerable group.
Most members of the multi-disciplinary team or carers will be able to recognise some dental
problems especially if the patient complains of a painful, dry or burning mouth or difficulty
in chewing. Broken, missing, decayed or loose teeth, soft tissue lesions, bleeding gums or
oral infections may be sufficiently visible to be an obvious problem. In some situations,
people may also report that their dentures are lost, broken, ill-fitting or unwearable. When a
patient refuses to eat or unexplained changes in behaviour occur, oral health problems should
be considered as a potential cause.
Dental caries is the disease process which destroys the hard layers of teeth. It is the
result of the demineralisation of enamel and dentine by acids produced as by-products of the
metabolism of fermentable carbohydrates by dental plaque microorganisms. This results in
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cavitation of specific sites on the tooth surface and as a consequence produces pain and
unsightly teeth. Caries is predominately a disease of childhood, although some effects are felt
in the very old. However, the treatment of caries and the repair of previous treatment requires
dental care throughout life. Preventive strategies involve either strengthening the teeth against
acid attack with fluorides, or addressing dietary issues such as the intake of food and drink
containing sugars [7] . Good oral hygiene alone is normally insufficient to prevent tooth
decay. Treatment of dental caries, once it has produced a cavity, involves either the
restoration or extraction of affected teeth.
Periodontal disease only occurs in the presence of dental plaque. It
progressively affects the gingival, periodontal ligaments and the alveolar bone of the jaws.
Initially the disease causes inflammation of the gingival and at this stage the process is
reversible. If it progresses to destroy the periodontal tissue (periodontitis), this is irreversible.
If allowed to progress unchecked, periodontitis will result in tooth loss. Preventative
strategies mainly involve reducing dental plaque levels by improved oral hygiene techniques.
As the initial stages of the disease are reversible, early intervention to improve oral hygiene
gives the greatest benefit.
Oral cancer has a similar level of mortality in the population as cervical cancer
and accounts for just over 1%of all malignancies in the UK [ 8]. The prevalence of oral cancer
increases with age and 98% of cases occur over the age of 40 years. The major causes of oral
cancer are smoking, chewing tobacco and alcohol consumption. Addressing these aspects is
the basis of a preventive strategy.
The detection of pre-cancerous lesions in the mouth brings major benefits. It
improves the survival rate and reduces the distress associated with some forms of radical
surgery or radiotherapy.
Tooth wear tends to increase with age. It may be caused by attrition (which is
the action of one tooth grinding upon another), abrasion (where the tooth surface is worn by
another agent, for example, a toothbrush) or erosion in which there is chemical dissolution of
the tooth. A major factor in the erosion of tooth enamel and dentine is an excessively acidic
diet, notably citrus fruits and carbonated drinks. Some studies have recorded over 40% of
some tooth surfaces affected by erosion associated with dietary acids [9]. Attention to diet is
the main focus for the prevention of tooth erosion.
Role of saliva
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Saliva plays an important role in oral health. It contains glycoproteins and
mucoproteins which lubricate the oral cavity and enhance food bolus formation, translocation
of food and initiation of swallowing. It also contains perioxidases and lysosymes which have
antibacterial properties.
Saliva buffers and neutralises acids produced by bacteria from foods. Saliva also facilitates
the articulation of speech.
Xerostomia (reduced salivary flow) has been implicated in a range of dental
conditions. Stiefel et al (1990) found increased plaque, calculus formation, caries, gingivitits
and soft tissue lesions in people with reduced salivary flow. Individuals with xerostomia were
also found to be at greater risk of root and coronal caries formation [ 10].The effect was
increased when multiple types of medication with xerostomic side-effects were taken.
Xerostomia also predisposes to oral candidiasis, especially in denture wearers.
Xerostomia can be induced by medication with anticholinergic side effects [ 11]. Some
autoimmune diseases, for example Sjogrens syndrome, and exposure to oral radiation may
cause severe xerostomia. Sialorrhoea, which is the over-production of saliva, is both
unpleasant for the patient and for others, leading to drooling and soreness of the face.
Sialorrhoea is a well known side-effect of clozapine and may improve after reduction in the
dose. If clozapine has to be continued, it is possible to treat the Sialorrhoea using
anticholinergic medication. Medication can produce a variety of other side-effects according
the dentist.
F9: Behaviour and emotional disorders with onset usually occurring in childhood and
adolescence
The DSM-IV-TR (Text Revision, 2000) consists of five axes (domains) on which disorder
can be assessed. The five axes are:
Axis I: Clinical Disorders (all mental disorders except Personality Disorders and
Mental Retardation)
Axis II: Personality Disorders and Mental Retardation
Axis III: General Medical Conditions (must be connected to a Mental Disorder)
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Axis IV: Psychosocial and Environmental Problems (for example limited social
support network)
Axis V: Global Assessment of Functioning (Psychological, social and job-related
functions are evaluated on a continuum between mental health and extreme mental
disorder)
1.2. 1 Depression
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A person having a major depressive episode usually exhibits a very low
mood, which pervades all aspects of life, and an inability to experience pleasure in activities
that were formerly enjoyed. Depressed people may be preoccupied with, or ruminate over,
thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness,
hopelessness, and self-hatred. In severe cases, depressed people may have symptoms of
psychosis. These symptoms include delusions or, less commonly, hallucinations, usually
unpleasant. Other symptoms of depression include poor concentration and memory
(especially in those with melancholic or psychotic features), withdrawal from social
situations and activities, reduced sex drive, and thoughts of death or suicide. Insomnia is
common among the depressed. In the typical pattern, a person wakes very early and cannot
get back to sleep. Insomnia affects at least 80% of depressed people. Hypersomnia, or
oversleeping, can also happen. Some antidepressants may also cause insomnia due to their
stimulating effect. A depressed person may report multiple physical symptoms such as
fatigue, headaches, or digestive problems; physical complaints are the most common
presenting problem in developing countries, according to the World Health Organization's
criteria for depression. Appetite often decreases, with resulting weight loss, although
increased appetite and weight gain occasionally occur. Family and friends may notice that the
person's behavior is either agitated or lethargic [14]. Older depressed people may have
cognitive symptoms of recent onset, such as forgetfulness and a more noticeable slowing of
movements. Depression often coexists with physical disorders common among the elderly,
such as stroke, other cardiovascular diseases, Parkinson's disease, and chronic obstructive
pulmonary disease.
Causes
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The researchers concluded that variation among the serotonin transporter (5-HTT) gene
affects the chances that people who have dealt with very stressful life events will go on to
experience depression. To be specific, depression may follow such events, but seems more
likely to appear in people with one or two short alleles of the 5-HTT gene. In addition, a
Swedish study estimated the heritability of depressionthe degree to which individual
differences in occurrence are associated with genetic differencesto be around 40% for
women and 30% for men, and evolutionary psychologists have proposed that the genetic basis
for depression lies deep in the history of naturally selected adaptations. A substance-induced
mood disorder resembling major depression has been causally linked to long-term drug user
or drug abuse, or to withdrawal from certain sedative and hypnotic drugs [15].
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The most widely used criteria for diagnosing depressive conditions are found
in the American Psychiatric Association's revised fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR), and the World Health Organization's
International Statistical Classification of Diseases and Related Health Problems (ICD-10),
which uses the name depressive episode for a single episode and recurrent depressive
disorder for repeated episodes. The latter system is typically used in European countries,
while the former is used in the US and many other non-European nations, and the authors of
both have worked towards conforming one with the other. Both DSM-IV-TR and ICD-10
mark out typical (main) depressive symptoms. ICD-10 defines three typical depressive
symptoms (depressed mood, anhedonia, and reduced energy), two of which should be present
to determine depressive disorder diagnosis. According to DSM-IV-TR, there are two main
depressive symptomsdepressed mood and anhedonia. At least one of these must be present
to make a diagnosis of major depressive episode. Major depressive disorder is classified as a
mood disorder in DSM-IV-TR. The diagnosis hinges on the presence of single or recurrent
major depressive episodes Further qualifiers are used to classify both the episode itself and
the course of the disorder. The category Depressive Disorder Not Otherwise Specified is
diagnosed if the depressive episode's manifestation does not meet the criteria for a major
depressive episode. The ICD-10 system does not use the term major depressive disorder, but
lists very similar criteria for the diagnosis of a depressive episode (mild, moderate or severe);
the term recurrent may be added if there have been multiple episodes without mania.
Management
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Chart nr 1 Zoloft (sertraline HCl) pills
Prognosis
Major depressive episodes often resolve over time whether or not they are treated.
Outpatients on a waiting list show a 1015% reduction in symptoms within a few months,
with approximately 20% no longer meeting the full criteria for a depressive disorder. The
median duration of an episode has been estimated to be 23 weeks, with the highest rate of
recovery in the first three months [17].
1.2.2 Schizophrenia
Symptoms
Causes
Diagnosis
Chart nr 2 John Nash, a U.S. mathematician and joint winner of the 1994 Nobel Prize for
Economics, who had schizophrenia. His life was the subject of the 2001 Academy Award-
winning film A Beautiful Mind.
According to the revised fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria
must be met:
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1. Characteristic symptoms: Two or more of the following, each present for much of the
time during a one-month period (or less, if symptoms remitted with treatment).
o Delusions
o Hallucinations
If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice
participating in a running commentary of the patient's actions or of hearing two or
more voices conversing with each other, only that symptom is required above. The
speech disorganization criterion is only met if it is severe enough to substantially
impair communication.
2. Social or occupational dysfunction: For a significant portion of the time since the
onset of the disturbance, one or more major areas of functioning such as work,
interpersonal relations, or self-care, are markedly below the level achieved prior to the
onset.
3. Significant duration: Continuous signs of the disturbance persist for at least six
months. This six-month period must include at least one month of symptoms (or less,
if symptoms remitted with treatment).
Management
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Some evidence indicates that regular exercise has a positive effect on the physical and mental
health of those with schizophrenia.
Prognosis
1.2.3 Dementia
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may become incontinent. A common symptom of dementia for dementia sufferers to deny
that relatives, even relatives in their immediate family, are their own relatives [22].
Causes
Various types of brain injury may cause irreversible but fixed cognitive
impairment. Traumatic brain injury may cause generalized damage to the white matter of the
brain (diffuse axonal injury), or more localized damage (as also may neurosurgery). A
temporary reduction in the brain's supply of blood or oxygen may lead to hypoxic-ischemic
injury. Strokes (ischemic stroke, or intracerebral, subarachnoid, subdural or extradural
hemorrhage) or infections (meningitis and/or encephalitis) affecting the brain, prolonged
epileptic seizures and acute hydrocephalus may also have long-term effects on cognition.
Excessive alcohol use may cause alcohol dementia, Wernicke's encephalopathy and/or
Korsakoff's psychosis [23].
Diagnosis
There are many specific types and causes of dementia, often showing slightly
different symptoms. However, the symptom overlap is such that usually it is impossible to
diagnose the type of dementia by symptomatology alone. Diagnosis may be aided by brain
scanning techniques. In some cases certainty cannot be attained except with brain biopsy
during life, or at autopsy in death. Proper differential diagnosis between the types of dementia
(cortical and subcortical) requires referral to a specialist.
Management
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1.2.4 . Mania
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relaxed high spirits to barely controllable exuberance, accompanied by hyperactivity, a
compulsion to speak, a reduced sleep requirement, difficulty sustaining attention and, often,
increased distractability. Frequently, confidence and self-esteem are excessively enlarged, and
grand, extravagant ideas are expressed. Behavior that is out of character and risky, foolish or
inappropriate may result from a loss of normal social restraint.
Cause
The biological mechanism by which mania occurs is not yet known. One
hypothesised cause of mania (among others), is that the amount of the neurotransmitter
serotonin in the temporal lobe may be excessively high. Dopamine, norepinephrine,
glutamate and gamma-aminobutyric acid also appear to play important roles. Imaging studies
have shown that the left amygdala is more active in women who are manic and the
orbitofrontal cortex is less active.
Treatment
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term anxiety covers four aspects of experiences an individual may have: mental
apprehension, physical tension, physical symptoms and dissociative anxiety. Anxiety disorder
is divided into generalized anxiety disorder, phobic disorder, and panic disorder; each has its
own characteristics and symptoms and they require different treatment. Standardized
screening clinical questionnaires such as the Taylor Manifest Anxiety Scale or the Zung Self-
Rating Anxiety Scale can be used to detect anxiety symptoms, and suggest the need for a
formal diagnostic assessment of anxiety disorder [27].
A1. Phobias
With panic disorder, a person suffers from brief attacks of intense terror and
apprehension, often marked by trembling, shaking, confusion, dizziness, nausea,
and/or difficulty breathing. These panic attacks, defined by the APA as fear or
discomfort that abruptly arises and peaks in less than ten minutes, can last for several
hours. Attacks can be triggered by stress, fear, or even exercise; the specific cause is
not always apparent. In addition to recurrent unexpected panic attacks, a diagnosis of
panic disorder requires that said attacks have chronic consequences: either worry over
the attacks' potential implications, persistent fear of future attacks, or significant
changes in behavior related to the attacks. Accordingly, those suffering from panic
disorder experience symptoms even outside specific panic episodes. Often, normal
changes in heartbeat are noticed by a panic sufferer, leading them to think something
is wrong with their heart or they are about to have another panic attack. In some cases,
a heightened awareness (hypervigilance) of body functioning occurs during panic
attacks, wherein any perceived physiological change is interpreted as a possible life-
threatening illness (i.e., extreme hypochondriasis) [29].
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C. 3 Obsessivecompulsive disorder
Causes
Biological
D4. Stress
Treatment
The most important clinical point to emerge from studies of social anxiety
disorder is the benefit of early diagnosis and treatment. Social anxiety disorder remains
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under-recognized in primary care practice, with patients often presenting for treatment only
after the onset of complications such as clinical depression or substance abuse disorders.
Medical definitions
In the modern medical profession, the three most used diagnostic tools in the
world, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders (DSM),the World Health Organization's International Statistical Classification of
Diseases and ICRIS Medical organization Related Health Problems (ICD), no longer
recognize 'drug abuse' as a current medical diagnosis. Instead, DSM has adopted substance
abuse as a blanket term to include drug abuse and other things.
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Signs and symptoms
Depending on the actual compound, drug abuse including alcohol may lead to
health problems, social problems, morbidity, injuries, unprotected sex, violence, deaths,
motor vehicle accidents, homicides, suicides, physical dependence or psychological
addiction.
Cause
Treatment
Psychological
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exposure therapy, contingency management . In children and adolescents, cognitive
behavioral therapy (CBT) and family therapy currently have the most research evidence for
the treatment of substance abuse problems. These treatments can be administered in a variety
of different formats, each of which has varying levels of research support [ 34] .Social skills
are significantly impaired in people suffering from alcoholism due to the neurotoxic effects of
alcohol on the brain, especially the prefrontal cortex area of the brain. It has been suggested
that social skills training adjunctive to inpatient treatment of alcohol dependence is probably
efficacious, including managing the social environment.
Medication
CHAPTOR II
Teeth of humans are small, calcified, hard, whitish structures found in the
mouth. They function in mechanically breaking down items of food by cutting and crushing
them in preparation for swallowing and digestion. The roots of teeth are embedded in the
maxilla (upper jaw) or the mandible (lower jaw) and are covered by gums. The anatomic
crown of a tooth is the area covered in enamel above the cementoenamel junction (CEJ) or
"neck" of the tooth. Most of the crown is composed of dentin (dentine in British English)
with the pulp chamber inside. The crown is within bone before eruption. After eruption, it is
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almost always visible. The anatomic root is found below the CEJ and is covered with
cementum. As with the crown, dentin composes most of the root, which normally have pulp
canals. A tooth may have multiple roots or just one root (single-rooted teeth). Humans usually
have 20 primary (deciduous, "baby" or "milk") teeth and 32 permanent (adult) teeth. Teeth
are classified as incisors, canines, premolars (also called bicuspids), and molars. Most teeth
have identifiable features that distinguish them from others. There are several different
notation systems to refer to a specific tooth [35].
The three most common systems are the FDI World Dental Federation
notation, the universal numbering system, and Palmer notation method. The FDI system is
used worldwide, and the universal is used widely in the United States.
Parts
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Chart nr 3 Section of a human molar
Enamel
Enamel is the hardest and most highly mineralized substance of the body. It is
one of the four major tissues which make up the tooth, along with dentin, cementum, and
dental pulp. It is normally visible and must be supported by underlying dentin. 96% of
enamel consists of mineral, with water and organic material comprising the rest. The normal
color of enamel varies from light yellow to grayish white. At the edges of teeth where there is
no dentin underlying the enamel, the color sometimes has a slightly blue tone. Since enamel
is semitranslucent, the color of dentin and any restorative dental material underneath the
enamel strongly affects the appearance of a tooth. Enamel varies in thickness over the surface
of the tooth and is often thickest at the cusp, up to 2.5mm, and thinnest at its border, which is
seen clinically as the CEJ [36].
Dentin is the substance between enamel or cementum and the pulp chamber. It
is secreted by the odontoblasts of the dental pulp. The formation of dentin is known as
dentinogenesis. The porous, yellow-hued material is made up of 70% inorganic materials,
20% organic materials, and 10% water by weight. Because it is softer than enamel, it decays
more rapidly and is subject to severe cavities if not properly treated, but dentin still acts as a
protective layer and supports the crown of the tooth.
Cementum
Pulp
The dental pulp is the central part of the tooth filled with soft connective tissue. This
tissue contains blood vessels and nerves that enter the tooth from a hole at the apex of the
root. Along the border between the dentin and the pulp are odontoblasts, which initiate the
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formation of dentin. Other cells in the pulp include fibroblasts, preodontoblasts, macrophages
and T lymphocytes. The pulp is commonly called "the nerve" of the tooth.
The periodontium is the supporting structure of a tooth, helping to attach the tooth to
surrounding tissues and to allow sensations of touch and pressure. It consists of the
cementum, periodontal ligaments, alveolar bone, and gingiva. Of these, cementum is the only
one that is a part of a tooth. Periodontal ligaments connect the alveolar bone to the cementum.
Alveolar bone surrounds the roots of teeth to provide support and creates what is commonly
called an alveolus, or "socket" [39]. Lying over the bone is the gingiva or gum, which is
readily visible in the mouth.
Periodontal ligaments
Alveolar bone
The alveolar bone is the bone of the jaw which forms the alveolus around teeth. Like
any other bone in the human body, alveolar bone is modified throughout life. Osteoblasts
create bone and osteoclasts destroy it, especially if force is placed on a tooth. As is the case
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when movement of teeth is attempted through orthodontics, an area of bone under
compressive force from a tooth moving toward it has a high osteoclast level, resulting in bone
resorption. An area of bone receiving tension from periodontal ligaments attached to a tooth
moving away from it has a high number of osteoblasts, resulting in bone formation [41].
Gingiva
The gingiva ("gums") is the mucosal tissue that overlays the jaws. There are three
different types of epithelium associated with the gingiva: gingival, junctional, and sulcular
epithelium. These three types form from a mass of epithelial cells known as the epithelial cuff
between the tooth and the mouth. The gingival epithelium is not associated directly with
tooth attachment and is visible in the mouth. The junctional epithelium, composed of the
basal lamina and hemidesmosomes, forms an attachment to the tooth. The sulcular epithelium
is nonkeratinized stratified squamous tissue on the gingiva which touches but is not attached
to the tooth.
Plaque
Certain bacteria in the mouth live off the remains of foods, especially sugars and
starches. In the absence of oxygen they produce lactic acid, which dissolves the calcium and
phosphorus in the enamel. This process, known as "demineralisation", leads to tooth
destruction. Saliva gradually neutralises the acids which cause the pH of the tooth surface to
rise above the critical pH. This causes 'remineralisation', the return of the dissolved minerals
to the enamel. If there is sufficient time between the intake of foods then the impact is limited
and the teeth can repair themselves. Saliva is unable to penetrate through plaque, however, to
neutralize the acid produced by the bacteria.
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Caries (cavities)
Tooth decay is caused by certain types of acid-producing bacteria which cause the
most damage in the presence of fermentable carbohydrates such as sucrose, fructose, and
glucose. The resulting acidic levels in the mouth affect teeth because a tooth's special mineral
content causes it to be sensitive to low pH. Depending on the extent of tooth destruction,
various treatments can be used to restore teeth to proper form, function, and aesthetics, but
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there is no known method to regenerate large amounts of tooth structure. Instead, dental
health organizations advocate preventative and prophylactic measures, such as regular oral
hygiene and dietary modifications, to avoid dental caries.
Treatment
Periodontal disease is a type of disease that affects one or more of the periodontal tissues:
1. alveolar bone
2. periodontal ligament
3. cementum
4. gingiva
1. gingivitis or
2. periodontitis.
This new classification divided plaque-induced periodontal lesions into four stages:
1. initial lesion
2. early lesion
3. established lesion
4. advanced lesion
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Accentuation of features of the initial lesion, such as the considerably greater
loss of collagen
Accumulation of lymphocytes subjacent to junctional epithelium
Treatment
The treatment of periodontal disease begins with the removal of sub-gingival calculus
(tartar) and biofilm deposits. A dental hygienist procedure called scaling and root planing is
the common first step in addressing periodontal problems, which seeks to remove calculus by
mechanically scraping it from tooth surfaces [46].
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Another method for treatment of periodontal disease involve the use of an orally
administered antibiotic, Periostat (Doxycycline). Periostat has been clinically proven to
decrease alveolar bone loss and improve the conditions of periodontal disease with minimal
side-effects. However, Periostat does not kill the bacteria, as it only inhibits the body's host
response to destroy the tissue.
Laser-assisted periodontal therapy has been shown to kill the bacteria that causes
periodontal disease as well as grow bone in certain cases.
Edentulism
Chart nr 6. This X-ray film displays two lone-standing teeth, #21 and #22, as the remnants of
a once full complement of 16 lower teeth. This case of partial edentulism is the result of
periodontal disease, as is suggested by the substantial bone loss around the two remaining
teeth.
Edentulism is the condition of being toothless to at least some degree; it is the result
of tooth loss. Loss of some teeth results in partial edentulism, while loss of all teeth results in
complete edentulism.
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Teeth serve to:
support the lips and cheeks, providing for a fuller, more aesthetically pleasing
appearance
maintain an individual's vertical dimension of occlusion
along with the tongue and lips, allow for the proper pronunciation of various sounds
Cause
Treatment
The treatment of a edentulism space can be done by implants if the pacients has
the finance and also the health sistem. Or with a fix phrostetic work if he has abutments
tooth.For the pacients that dont not have teeth they can be treat by a removable phrostodontic
work [47].
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Chaptor III
Mental illness affects people of all nations and at all economic levels. One of
the primary targets of the health of a nation should be to improve the health and social
functioning of mentally ill people. Psychiatric disorders affect the general behavior of
a person, impair level of functioning, and alter perception. This group is often
neglected because of ignorance, fear, stigma, mis conception, and negative attitudes.
There are several factors that contribute to poor oral health in patients with psychiatric
disorders. These include saliva reducing medications being taken, poor diet, and
apathetic nature of many psychiatric patients. The most common side effect of the
psychotherapeutic medications is the reduction in salivary secretions, leading to a
wide array of oral diseases. Sialorrhea, dysphagia, sialadenitis, dysguesia, stomatitis,
gingivitis, glossitis, tongue edema, discolored tongue, and bruxism are other
complications reported. Studies on psychiatric patients have shown a relatively high
frequency of non-compliance with oral health practices, which represent a major
problem in dental care for hospitalized psychiatric patients . Reports have indicated
that the oral health of psychiatric patients is poor and have large treatment needs [48].
Among the unique population groups deserving special attention are patients
with psychiatric and mental disorders. To date, only few studies have been conducted
to determine the oral health status and treatment needs of institutionalized psychiatric
patients in Romania. Since very few data are available, this study was undertaken
with the following objectives:
Compare to that a lot of studies were made in world about this topic only that the
result were different. For example in Department of Caring Science, Vasa, Finland was made
a studies on oral health status of psychiatric patients. Many patients suffering from long-term
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psychiatric illness are on medication for long periods [ 49]. These medications frequently cause
xerostomia leading to an increased risk of caries, gingivitis, periodontitis and stomatitis. Oral
hygiene is therefore of the utmost importance for these patients. Nurses interact with patients
on a daily basis, and therefore they are the psychiatric caregivers of choice to support these
patients. The main aim of this study was to describe the oral health status of patients in short-
term and long-term psychiatric care by means of oral assessment. A second aim was to
discover whether the assessment guide used could distinguish any differences between these
two groups. A total of 57 patients in psychiatric care, short-term (n = 32) and long-term (n =
25), were assessed by the OAG-PC. Patients in long-term psychiatric care had significantly
higher scores on the total OAG-PC compared with those in short-term psychiatric care,
indicating a worse oral health status.
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In a other studie by Department of Preventive and Community Dentistry, Darshan
Dental College and Hospital, Loyara Udaipur, Rajasthan, India the aim is To assess the oral
health status of the Bhil tribal population of Southern Rajasthan and to investigate the
association of age, oral hygiene and dental visiting practices with oral health status. The total
sample size was 1590 male tribal dentate subjects aged 15-54 years. Clinical recordings of
oral hygiene status (OHI-S), caries status (DMFT and DMFS) and treatment needs, and
periodontal status (CPI). The Chi square test was applied to discrete data and one way
ANOVA for continuous data. Multivariate analyses were carried out to test the association of
age, frequency of cleaning teeth, material used for cleaning teeth and dental visiting habits
with caries and periodontal status.
The results was debris, calculus and oral hygiene index scores increased with age.
The overall mean DMFT and DMFS scores were 5.34 +/- 6.48 and 18.94 +/- 35.87
respectively. Extraction was the most required treatment (1.74 +/- 3.66 teeth) followed by one
surface fillings (1.34 +/- 1.65 teeth). Shallow periodontal pockets were prevalent (40%)
among the 35-44 years age group whereas deep pockets were most common (11.6%) in the
oldest age group. More than half the sextants (3.15) were excluded amongst the oldest study
group. All the independent variables namely age, frequency of cleaning teeth, substance used
for cleaning teeth and visiting habits were statistically significantly related to caries and
periodontal status. The conclusion is the study population was characterised by a lack of
previous dental care, high treatment needs, high prevalence of periodontal disease and poor
oral hygiene. Under these circumstances, the implementation of a basic oral health care
programme for the Bhil population is a high priority [52].
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PRACTICAL
PART
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Chapter 1. Objectives of the study
Today, there are increasingly more and more new cases of mental illness in
population. Therefore, its becoming increasing important to access the impact of mental
illness on oral health and the relationship between oral health and mental illness.
It is the duty of the dentist to identify and properly treat patients in this category.
2. The way and the type of treatment given to mental ill patients.
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Chapter 2. Material and methods
The trial was conducted at the Department of Psychiatry and neurology of UMF Cluj,
and the study was conducted on 52 patients out of 87 who were asked to take part..
The investigation was carried out between 25 of May 2012 till 25 of May 2013. The
study included both sexes between 18-67 years. The selection of patients was done according
to the following inclusion and exclusion criteria.
Included criteria were the patients group of Caucasian origins, aged between 18-67
years who were hospitalized and being treated for mental illness at the department of
psychiatry of UMF Cluj.
The above group of patients were monitored and investigated over a period of one year:
2. Evolution of oral health of patients during their stay at the psychiatry hospitalized.
A written patient consent was request from patient or their guidance before their inclusion
on the thesis.
43 | P a g e
was used to explore the depth of the periodontal pocket. A plaque staining solution was used
to highlight calculus to aid in the determining of the calculus index. To calculate the index we
used gingival bleeding index (Loe and Silness) and papillary bleeding index (Mhlemann).
For periodontal inflammation indices we used periodontal index (Russell) and the index of
the presence of periodontal pockets. For diagnosis of edentulism or missing teeth was
represented as follows. Patients with 1-3 teeth missing were represented as partial edentulism
whilst patients with more than 4 teeth missing on the same arch were represented as extended
edentuslism.
From the group of patients observed during the year of study at the UMF Cluj
department of psychiatry, 21 of the patients had depression, 6 schizophrenia 9 suffered from
drug abuse , 7 from dementia and 9 had anxiety problems. All patients were evaluated and
categorised under, cavity, parodontal problem, edentation and oral hygiene.
The severity of the odontal disease the patients presented were categorised according
a score from 1-3. 1 representing patients with no problems and 2 representing patients with
less than 10 cavities and patients with more than 10 cavities were scored with 3.
Patients with periodontal were categorised as the following. 1 for patients without
periodontal problems and 2 for patients with gingivitis and 3 for patients marginal
periodontitis.
Patients with edentation were classified as follows. Patients without edentation were
given a score of 1 and patients with less than 2 edentation were scored with 2 and patients
with more two were scored with 3.
Oral hygiene patients were scored as follows. Patients without tartar were scored with
1 and patients with moderate tartar involving less than 10 teeth were scored with 2 and
patients with more than 10 tartar were scored with 3.
The results for all the total index above was represented as follows. The sum total of
all dental disease without any pathology was score four points representing (1 point for
cavities, 1 point for periodontal diseases, 1 point for edentation and finialy point oral hygiene.
The sum total of patients with average dental pathology was score as follows. The
average index which is represented by two is the sum of all the four categories which would
have a highest point of 8 and a minimum point of 5.
44 | P a g e
Severe pathology was represented by score point of three meaning the sum total of all
dental pathologies fell between 9 and 12 points.
The data from the average was further subjected to (TTest) analysis comparing the
average between different patient pathologies. The results obtained from the analysis were
marked with p meaning 0.05. If the results obtain was less than 0.05 then there was a
statistical difference between them. If the results was more than 0.05 then there was no
significance between them.
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In terms of distribution by age group, 12 cases were patients aged 25 years, 8 cases were
patients aged betwen 26-35 years, 23 cases were patients aged 35-55 years, 9 cases patients
older than 55 years (Chart 1).
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Chart nr 2 Distribution of patients according their sex
From the group of 52 patients, 40 were from urban and 12 from rural areas (Chart 3).
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Chart nr 3 Distribution of patients according to area of origin
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Chaptor 3. Results
Regarding general clinical examination of the study group was found as a general
cardio-vascular pathology (HTA) 10 cases, those with respiratory diseases (asthma) 5 cases,
digestive disorders (ulcers) 3 cases (Chart 4).
The data obtained from the history, the cases studied showed the presence of risk
factors in 18 patients with systemic diseases (Chart 5).
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Chart nr 5 Distribution of patients according to their general status
50 | P a g e
Chart nr 6 Distribution of patients according their hereditary psychiatric disease
51 | P a g e
Chart nr 7 Distribution of patients according their mental illness
52 | P a g e
Chart nr 8 Distribution of patients according family support
Following anamnesis, it was established the reason patients presented themselves for
treatment were as follows : for pain related 36 patients, routine checkup 9 patients and forced
by or pressured by family 6 patients.(Chart nr 9)
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Chart nr 9 Distribution of patients according the reason of visiting the dental clinic
Following clinical examination of the periodontal group under observation were found 50
patients with plaque, gingivitis 46 cases and 14 cases with pockets (Chart nr 11).
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Chart nr 11 Distribution of parodontal diseases after clinical exam
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Chart nr 12 Distribution of edentation according to size
Also by anamnestic examination we could assess the level of hygiene of the oral
cavity as well as through local clinical examination, reaching results: 13 cases were
satisfactory hygiene (brushing 2/day, using oral hygiene aids) and 39 cases poor hygiene
(brushing 1/day or less). This is due to the low standard of living, combined with a low
education index (Chart nr 13).
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Chart nr 13 Distribution of patients according their degree of oral hygiene
From the questionnaire we concluded that 29 patients did not even brush their teeth
once a day, 19 patients wash one day and 8 patients 2 times per day (Chart nr 14).
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Chart nr 14 Distribution of patients according daily brushing of teeth
The distribution of patients according to the methods used auxiliary brush we found that 3
patients floss, use mouthwash 8 patients and 1 patient using interdental brushes (Chart nr 15).
59 | P a g e
Chart nr 15 Distribution of patients according other auxiliary methods of brushing
60 | P a g e
Chart nr 16 Distribution of patients according their technique of brushing
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Chart nr 17 Distribution of patients according the previous dental work
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Chart nr 18 Distribution of prosthodontic work on patients
Distribution of patients according the cooperation with the dentist. 62% of the patients did
not cooperate with the dentist (Chart nr 19).
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Chart nr 19 Distribution of patients according the cooperation with the dentist
As the smoke, which is a risk factor in dental disease have been identified by medical
history that 35 cases are smokers (Chart nr 20).
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Chart nr 20 Distribution of patients according their bad lifestyle
Considering the general medication the patients were taken it was observed that
they have some secondary effects after treatment. 21 patients with xerostomia, 15 patients
with stomatitis and 7 patients with change taste (Chart nr 22).
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Chart nr 22 Distribution of patients according to secondary effects after taking psychiatric
medication
3.3 The relation between the oral health and mental illness
A comparision of dental disease was done for the case study patients on their
individual mental illness. For example for each patients suffering from the following
depression, schizophrenia, drug abuse, and anxiety we calculate the total dental pathology
associated with odontal, parodontal, prosthetic disorders and oral hygiene.
66 | P a g e
Patients Depression Schizophrenia Drug abuse Dementia Anxiety
Patient 1 2 2 2 2 3
Patient2 2 3 2 3 2
Patient3 2 3 2 2 2
Patient4 3 3 3 2 2
Patient5 2 3 2 2 2
Patient6 2 3 3 3 3
Patient7 3 2 2 2
Patient8 2 3 2
Patient9 2 3 2
Patient10 2
Patient11 3
Patient12 2
Patient13 2
Patient14 2
Patient15 3
Patient16 2
Patient17 2
Patient18 2
Patient19 2
Patient20 3
Patient21 2
Average 2.238095 2.833333 2.444444 2.285714 2.222222
67 | P a g e
Chart nr 24 Average of median for diseases
The data from the average was further subjected to (TTest) analysis comparing the
average between different patient pathologies. The results obtained from the analysis were
marked with p meaning 0.05. If the results obtain was less than 0.05 then there was a
statistical difference between them. If the results was more than 0.05 then there was no
significance between them.
From the (TTest) the signicant values of p is between depression and schizophrenia
(0.003) and al so between schizophrenia and dementia (0.01) and finialy schizophrenia and
anxiety (0.004).
The median was calculated for all the patients and the results are as follows, patients
with cavities the mean was 2.25, patients with periodontal disease the mean was 2.18 patients
with edentation the mean was 2.43 and finally patients with oral hygiene problems the mean
was 2.37.
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Chart nr 26 Avarege of the oral diseases
In the chart above it can be observed that patients with edentation had the most dental
pathlogy and patients with periodontal disease had the least dental patholgy.
Chaptor 4. Discussion
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In our studies we observed that significant percentage of patients from cities
suffered from mental illness which was similar with Genco et al. 1999 investigations.
Moreover we observed that the reason that patients with mental illness were
taken to the dentist was in 70% of the cases were pain on teeth, compare to a study done in
Sweden were they were coming more for routine checkup.
In our study according the clinical exam the highest percentage of the issues
that patients with mental illness presented were dental decays (30%) which is similar to
Annsofi Johannsen in 2006 the caries prevalence was 32.2%.
Folling the edentations exam more than 52% in our studies had large
edentation compare to Kumar M a very low percentage of psychiatric patients in this study
were found to be edentulous (3.3%). But a higher percentage was found in other studies;
Vigild M et al reported 63%, 31.7% by Velasco and Bullon, 63% by Lewis S et al. The low
prevalence of edentulousness in the present study might be due to relatively young age (mean
age 36.7 years) compared to other studies.
70 | P a g e
The mean decayed teeth (DT) was found to be very low (0.6) in our study,
comparable to other studies; Vigild M et al reported 1.3 decayed rate and Lewis S et al
reported 0.9 decayed rate. 23.6% of the psychiatric patients had untreated decayed teeth and
18.9% required restorative care in accordance with the study by Lewis S et at.
The prevalence of missing teeth due to caries (18.9%) in the present study was
found to be higher than filled teeth. The filled component was almost non-existent, as no
regular treatment was available to the study population.
In the present study, 29.9% required extraction and was in accordance with
other studies. This might be a reflection of long standing treatment needs. In contrast, other
studies have reported higher prevalence of extraction needs; 80.7% byAngelillo IF et al ,
Kenkre and Spadigam reported 75.6% extraction needs.
Virtually 98.1% of the patients required oral hygiene instructions and 87.6% required
oral hygiene instructions and oral prophylaxis. This finding is consistent with other studies.
Only 7.8% of the study population required complex periodontal therapy. This was in contrast
to other studies; Angelillo IF et al reported 64.8% were in need of complex periodontal
therapy, whereas Lewis S et al reported only 1% requiring complex periodontal therapy.
In our studies we evaluate that 62% of the patients are not cooperant with the
dentist the same results with Genco et al 2006 research.
Chapter 5. Conclusion
1. More than 70% of patients that visit the dentist comes because of pain. Small
percentage visit the dentist for routine check up or urged by family and friends to do
so.
2. It was observed from the clinical examination that of mental patients that the
distribution of dental pathology was evenly spread among the patients with large
edentulism being the highest percentage.
71 | P a g e
3. The increase level of edentulism among mental patients can be explained by the fact
that dentist tend to assume mental illness patients need more care of their prosthetic
work and most mental patients do not take care of their prosthesis as require.
4. 75% of patients had unsatisfactory oral hygiene due to the fact that they did not brush
their teeth at all
5. The highest mental illness from our observation was schizophrenia followed by
dementia and lowest was anxiety.
The results of this study showed that psychiatric patients have extensive dental
diseases, many of them requiring complex treatment. However, prevention should be the
main objective because patients with advanced mental illness are often anxious and unco-
operative in the dental clinic, thereby precluding complex treatment. No dental treatment was
provided in these hospitals except referral to the dental surgeon for emergency treatment.
Hence more coordinative efforts between medical, dental, and social care sectors must be
established to serve the needs of this underprivileged population.
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