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INTRODUCTION PSYCHIATRIC DISORDERS AND ORAL HEALTH PSYCHOGENIC ORAL DISEASES PSYCHIATRIC MEDICATIONS AND ORAL HEALTH DRUG INTERACTION CONCLUSION
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
Introduction Persons with co-morbid mental and oral disorders are part of patients presenting to various dental health facilities. This presents challenges to dental personnel in terms of diagnosis and treatment .
Hence, this presentation seeks to elucidate the relevant nexus between mental and oral health
Introduction The 3 dimensions that unite oral and mental health: PSYCHIATRIC DISORDERS AND ORAL HEALTH
Dental
anxiety
Psychosis Mood
disorders
Substance abuse
Dental Anxiety has been defined as a state of unpleasant feelings combined with an associated feeling of impending doom or danger from within rather than from without. On the other hand, dental fear is a response to a real or active threat which is usually brief.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
Some clinical features of dental anxiety include: 1. Excessive worry over oral health and its treatment procedure 2.Recurrent unexplained symptoms of oral pathology such as oro-facial pain, headache 3. Excessive sweating most especially on the palm 4. Trembling 5.Shortness of breath 6.Somatic symptoms (such as crawling sensation, internal heat etc) 7. Palpitation.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
Types:
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Epidemiology
In
a recent study in Nigeria by Coker et al (2008), 29% of attendees in a dental Clinic had dental anxiety and this figure is lower than most of those obtained from studies in the western world such as Wake (1999); Moore (2004) and Kloosa et al (2007). The global estimate for dental anxiety has been put at 615% (Eli et al, 2004).
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When compared with prevalence figure of 29% for Nigerian adults attending dental clinic, figures in children are comparatively slightly higher.
For instance, Sote and Sote (1985) found 29.8% while Folayan (2000) obtained 33.7% for dental anxiety among children attendees of hospital based dental clinics in Nigeria.
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MANAGEMENT
Preventive
1. Dental health education 2.Procedures should be honestly explained Definitive 1. Psychological/behavioural 2.Pharmacological
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Psychological
management Minimize dental anxiety triggers; that is the 4S rule which aims to reduce the triggers of stress, such as:
Sight Sound Sensation Smell
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1.The 4S rule: Sights (of Needles, drills): placing instruments where they are blocked from view or covered.
Sounds (drilling): reduce the offensive sound to
bonding agents): spray a scented oil fragrance to reduce the clinical aroma of the treatment room.
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2.Relaxation therapies -Jacobsens muscular relaxation -Overbreathing exercise 3.Distraction techniques 4.Systematic desensitization 5.Cognitive behavioural therapy
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Pharmacological
approach
1.Anxiolytic agents; premedication and/or parenteral .Examples Diazepam, midazolam 2.Anaesthetic agents- Nitrous oxide, Oxygen 3. Antidepressants(in chronic cases)
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Psychosis
is a form of mental illness characterized by hallucination, delusion and personality disorder. It includes the following: 1.Schizophrenia
2.Schizophreniform
3.Schizoaffective
disorder
disorder
4.Delusional
disorder
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Epidemiology In a study conducted by Janardhanan & colleague (2011) in US, 41 of the studied population with schizophrenia reported having problems with their teeth or dentures. Akpata et al ( 2006) reported increasing prevalence of delusional halitosis in a university community.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Dental
presentations
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Could
be
individuals mood, thought content and behavioural pattern between extreme elation (mania) and depression
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Ten key symptoms of depression: Depressed mood (for>2weeks) Loss of interest and pleasure (anhedonia) Loss of confidence and self-esteem Self-reproach or guilt Recurrent thoughts of suicide or death Diminished concentration or indecisiveness Fatigue and loss of energy Agitation and psychomotor retardation Sleep disturbance (e.g early morning waking) Appetite and weight change (usually lost)
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Manic symptoms: 1.Execessive high or euphoric feelings 2.Obnoxious, provocative or intrusive behaviour 3.Unrealistic beliefs in ones abilities 4.Difficulty concentrating, remembering and making decisions. 5. Denial that anything is wrong
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Dental presentation Mania 1. Overzealous tooth-brushing and flossing 2. Demand for expensive cosmetic dental treatment
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Substance use is the consumption of low or infrequent doses of alcohol or drugs such that damaging consequences are rare or minor. Substance abuse is a disorder characterized by repetitive drug use that results in social or economic distress with related medical problems.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Epidemiology Globally, 200 million people abuse drugs(2007). Studies from Nigeria showed prevalence rate of 2-9% among secondary school students; and the rates are much higher among university undergraduates.
In a Nigerian university survey, 33% of the male students and 2.2% of females admitted smoking cannabis. It is also the most incriminated substance in a survey of drug-related admissions for in-patient management in 28 psychiatric facilities in Nigeria.
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Marijuana, Hashish
Stimulants-
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Commonly abused drugs contd: Hallucinogens- Lysergic acid diethylamide(LSD), Mescaline, Psilocybin
Depressants-
Alcohol, benzodiazepines,
barbiturates
Miscellaneous:
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malignancies
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Oral lesions in Cocaine: Cervical abrasion, gingival laceration and/or recession 2 to overzealous brushing when high.
Bruxism TMJ
disorders
Glossitis
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Oral lesions in Methamphetamines: Meth mouth- the term used to describe effects of methamphetamine on oral hard and soft tissues. Dental caries( smooth surface) Xerostomia Gingivitis Periodontitis Bruxism
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Parotid enlargement)
caries diseases
Periodontal Oral
malignancy
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These
Emotional
Stress
Depression Anxiety
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To describe experience of being stressed To describe an emotional disorder associated with stress Used in a negative sense BUT can be positive What is stressful to one person may not be to another coping skills
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Some
physical diseases are believed to have a mental component derived from the stresses and strains of everyday living Anxiety and stressful life events can give rise to oro-facial symptoms
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Irritable bowel syndrome Hypertension Low back pain Chronic fatigue syndrome
Psychogenic oral diseases: TMPDS Oral dysaesthesia Disruptive gagging Dry mouth Anorexia nervosa Atypical facial pain Tension headache Panic attacks
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The
dentists must always eliminate any organic cause for patients symptoms before diagnosing them as psychosomatic disorder. queries during history taking.
Helpful
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How Has
are you sleeping? your appetite been affected by this condition? the complaint stop you from enjoying yourself
Does How
Does
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(TMPDS).
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Delusional
symptoms:
Delusional/Psychogenic halitosis Phantom bite syndrome Lump or seeds under the mucosa
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Self
Eating
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Atypical Odontalgia
Atypical odontalgia
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Pain
is the commonest symptom seen in dentistry. Pain in the face and mouth may be of a local pathology, may be referred or may have no organic basis (psychogenic). About 50% of psychogenic pain are based in the head and neck.
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Pain
due to muscle tension (anxiety, depression, hypochondriasis). Anxiety muscular tension metabolites pain metabolites pain Conversion hysteria-repression of emotional conflict and conversion to somatic symptoms. Pain may be an hallucination or psychotic disorder (endogenous depression, schizophrenia).
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Pain
distribution not consistent with anatomical distribution. Pain may cross the midline or may occur bilaterally. Pain is usually continuous over a long period of time with no remission or change in xter. Pain may prevent patient from sleeping but it does no wake patient from sleep.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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There
may be a long history of various investigation with no organic pathology. Previous treatments including use of analgesics may have produced transient or no appreciable relief. Pt may describe the pain as being clearly associated with emotional factors and description may produce emotional outpouring.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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women
dull ache
Aggravated Does
Non-muscular
Lasts
Recent
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Occur
more frequently in elderly females Presents as dull, poorly localized vague dull ache in the soft tissue or bone. Distribution of pain is not anatomical. May complain of other associated pain e.g back pain, body ache. Associated symptoms may include fatigue, sleep disorders, tension, irritability and lethargy.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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80%
Irritable bowel syndrome Dysmenorrhoea Tension headache Fibromyalgia Chronic fatigue syndrome
Considerable
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Detailed
history (of emotional disturbance) and careful assessment to R/O organic causes. patient.
Reassure
Antidepressants-TCA, MAOI.
Psychiatric
consultation(if necessary).
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Teeth
radiographically sound
Pain
extraction OR
Moved
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Specifically
of oral mucosa Comprises glossodynia (painful tongue), glossopyrosis (burning tongue). May be accompanied by metallic taste or dry mouth). There may be evidence of neurotic depression and anxiety disorder.
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Two forms: A. With observable clinical signs and symptoms Undiagnosed DM, Vitamin B complex deficiency Pernicious anaemia, Iron deficiency anaemia, Prosthetic/orthodontic appliance, Medicaments, dentrifices, Rarely allergy to cosmetics, Malignancy of the tongue, Lichen planus, Trauma, Candidiasis
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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B.Without observable clinical signs and symptoms. Forms the larger group Occurs in women in 4th 7th decade of life. Pain without observable signs and symptoms Pain is usually psychogenic
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Detailed history Thorough clinical examinations Investigations to R/O organic diseases Fe def anaemia, pernicious anaemia, candidiasis., geographic tongue.
Full blood count Random blood sugar( FBS, 2hr-PP) Urinalysis
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Definition:
Burning sensation in the oral cavity with apparent clinically normal mucosa
Gender
distribution: M:F = 1:7 Age peak: 50 yrs. Sites most commonly affected: Tongue Palate Lips
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Type 1: Symptom-free waking, with sensation develops in the morning and progressively increasing to severe by evening Type 2: Continuous symptoms throughout the day Type 3: Intermittent symptom-free periods throughout the day
Day hours
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Systemic factors
Psychogenic factors
Local factors
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Systemic
Local
Fe
Folic acid Diabetes mellitus
Menopause
Psychological
Allergy (? Restorative or
Cancer phobia
Anxiety Depression
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Detailed
investigations (for Candida species) Assessment of salivary gland function (salivary flow rate)
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Pain
(burning) control
Topical anaesthetics
Antidepressants
consultation
Anxiolytics
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Positively
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Management Good history and clinical examination Relevant investigations Counselling Drugs Physiotherapy Soft diet Review
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Is
Examples: Delusional halitosis Phantom bite syndrome Lumps or seeds under the mucosa Management: Organic causes should be eliminated Psychological assessment & referral
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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This is a disorder whereby a patient complains of mouth odour that cannot be clinically substantiated or perceived by others. The patient insists in the presence of this odour despite argument to the contrary from significant others and the dental practitioners. In some of such patients, halitosis could be a manifestation of underlying uncinate fit or bizarre delusion seen in schizophrenic or severly depressed patients.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Body
dysmorphic disorder (BDD) is an obsessive preoccupation with a perceived defect in one's physical appearance. The individual persistently seeks medical attention to correct surgically. BDD often goes unrecognized and undiagnosed, due to patients' reluctance to divulge their symptoms because of secrecy and shame.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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This
preoccupation causes clinically important distress or impairs work, social or personal functioning Encourages gratuitous seeking of help from various physicians thereby causing much time wasting and high expenses. The individual is never satisfied with the outcome of any corrective surgery done.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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The
obsessions are most frequently focused on the head and face though any body part can be the focus of concern (most often, the skin, hair, and nose), Most patients engage in compulsive behaviors, such as mirror checking, camouflaging, excessive grooming, and skin picking. Psychiatric hospitalization, suicidal ideation, and suicide attempts are relatively common.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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The patient has a serious preoccupation with an aspect of his / her physical appearance that they feel is defective Any part of the body
Patient seek corrective treatment Dental treatment may enhance the patients preoccupation
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The
doing anything is better than doing nothing approach : this confirms the patients belief of a disease that is nonexistent Beware of litigation !
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Cognitive-Behavioral
Therapy (CBT)
PHARMACOTHERAPY
-SSRIs (Selective Serotonin Reuptake Inhibitors) clomipramine, fluoxetine, fluvoxamine, sertraline, and paroxetine OF 1 & 2
Tuesday, August 14, 2012
COMBINATION
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Non-intentional
Severe gout and kidney Epilepsy problems, poor muscle Cerebral palsy control, and moderate mental retardation Autism Lesch-Nyhan syndrome Riley-Day syndrome (familial dysautonomia) Insensitivity to pain, inability to produce tears, poor growth, and labile blood pressure
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Intentional
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Complications
Malnutrition & dehydration Renal failure & liver dysfunction Amenorrhoea Sialosis
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Binge
eating and purging through vomiting, taking excessive laxatives More common than AN (2% of adult F) Usually normal over body weight Psychological problem
Role
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Oesophygeal K+ depletion
erosions
(hypokalaemia) myocardial
Sialosis
Traumatized Nutritional
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These include: Orofacial manifestations of antipsychotic side effects. Xerostomia Sialorrhoea/ Ptyalism Gingival hyperplasia Lichenoid stomatitis
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Examples are: 1. Haloperidol 2. Chlorpromazine 3. Trifluoperazine The side effects are extrapyramidal
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Tardive
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Acute dystonic reactions Movement disorder that causes sustained muscle contraction, repetitive twisting movements with abnormal postures of the trunk, neck, face and limbs.
It
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Clinical features: Tremor Torticolis Oculogyric crisis Twisting and protrusion of the tongue Dislocation of TMJ(Cenker e tal;2009)
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exposure
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Drug induced Parkinsonism Treatment Conventional antiparkinsonism agent of antimuscarinic type( atropine).
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Condition
characterised by persistent, stereotyped, repetitive abnormal involuntary movements of the facial muscles and the tongue associated with chronic exposure to antipsychotic drugs (especially phenothiazine) which bind and blocks the dopamine receptor. Cause is related to dopamine receptor supersensitivity.
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Prevalence
increases with age Common in elderly women People with schizophrenia are vulnerable to developing tardive dyskinesia after exposure to conventional neuroleptics, anticholinergics, toxic substances of abuse and other agents e.g. cigarrettes.
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Subtypes:
Orofacial TD Buccolingual TD Masticatory TD Others Tardive akathisia subjective state of motor restlessness or an aversion to being still.
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Treatment: Use of minimum effective dose of neuroleptics. Discontinue the drug. Reserpine starting with 0.25mg ands gradually increasing to 5.0mg / day.
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Xerostomia Xerogenic drugs of importance in psychiatric practice are: Antidepressants1. TCA( Imipramine) 2. Selective serotonin reuptake inhibitors(SSRI)-Fluoxetin 3. Monoamine oxidase inhibitorsPhenelzine
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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Mood stabilizing drug- Lithium carbonate Antipsychotic agents- Haloperidol, Chlorpromazine, Fluphenazine, Risperidone Sedatives- benzodiazepine
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Treatment: Frequent sipping of water Chewing of sugar-free gum e.g Xylitol Secretagogues- Pilocarpine, Cevimeline Saliva substitutes-artificial saliva e.g Orthana, Oralbalance
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Sialorrhoea/Ptyalism
Atypical Can
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Gingival hyperplasia Generalized and not related to poor oral hygiene. Anticonvulsant- phenytoin Mood stabilizing drug- Lithium
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Lithium
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Decreased effect of local anaesthesia in alcoholics Increased dose of induction agents in G.A Profound depression of CNS under G.A Sympathomimetic effect of Marijuana potentiates epinephrine in L.A and retraction cord. Lithium and Flagyl or Tetracycline-renal retention of Lithium
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In view of the significant interplay between the mental and oral health( illness), it is most appropriate for the dentists to have an open mind and high index of suspicion while managing patients with underlying emotional disturbance or co-morbid psychiatric disorders. This will make for prompt and accurate diagnosis, proper intervention or referral for psychiatric consultation.
B.A. FAMUREWA, B.ChD Tuesday, August 14, 2012
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1. 2. 3. 4. 5. 6. 7. 8. 9.
Tyldesleys Oral Medicine 5th edition by Anne Field and Lesley Longman. David B.Clark. Dental Care for Patients with Bipolar Disorders. J Can Dent Assoc 2003 Terry D.Rees. Oral Effects of Drug Abuse. Crit Rev Oral Biol Med 1992 Irene Cormac, Philip Jenkins. Understanding the importance of Oral health in psychiatric patients. Advances in Psychiatric Treatment 1999 Agbelusi G.A. Psychiatric Disorders in Dentistry. NPMCN Revision Course 2006. Aina O.F. Co-morbid Psychiatric Disorders in Dental Practice. NPMCN Revision Course 2009. Scully C, Bagan- Sebastian J.V. Adverse Drug Reactions in the Orofacial Region. Crit Rev Oral Biol Med 2004 Psychiatry Problems in Dentistry by Ian Macleod and Stephen Potts Jumana Karasneh. Lecture note(Dent 555); Psychogenic Oro-facial Problems
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