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PSYCHIATRIC PROBLEMS IN DENTISTRY

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... PROBLEMS IN DENTISTRY. By. Iain Macleod ... Aliens are controlling me through transmitters implanted under my ... Look at my tongue. I'm really ... – PowerPoint PPT presentation

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Title: PSYCHIATRIC PROBLEMS IN DENTISTRY


1
PSYCHIATRIC PROBLEMS IN DENTISTRY
  • By
  • Iain Macleod
  • Stephen Potts

2
Royal Bethlehem Hospital Bedlamc18th
3
Classification of psychological disorders
  • Neurosis
  • Psychosis
  • Disorders of personality and behaviour
  • Substance misuse
  • Learning disability
  • Organic problems

4
Neurosis v Psychosis
  • Schizophrenia,Manic Depressive illness
  • Qualitatively different
  • Delusions Hallucinations Thought disorder
  • Rare
  • Anxiety, Depression, Somatisation
  • Quantitatively different
  • Excessive degrees of normal phenomena
  • Common

5
Dental presentation - Psychosis
  • Aliens are controlling me through transmitters
    implanted under my fillings…..
  • I want them out.

6
Dental presentation Neurosis
  • Look at my tongue. Im really worried its
    cancer. I know you said before its not, and I
    felt better for a while, but I cant stop
    thinking about it, especially since that man on
    the telly said it was on the increase.
  • I want you to check me out again and this time I
    want a scan.

7
Anxiety and depression (emotional disorders)
  • Both are extensions of normal emotions
  • Signs and symptoms of anxiety are due to
    sympathetic overactivity fright/fight/flight
    response
  • Anxiety due to specific trigger phobia
  • Generalised anxiety anxiety trait
  • Severe form panic attack
  • Can get combined anxiety and depression

8
pathophysiology
TRIGGER
SYMPATHETIC ACTIVITY
HYPERVENTILATION
PANIC
RESPIRATORY ALKALOSIS
CATASTROPHIC INTERPRETATION
BODY SENSATIONS
9
Depression
  • Various sub-types
  • Unipolar and bipolar (with mania)
  • Can be acute or chronic
  • Genetic factors may be present (family history)
  • Can lead to suicide
  • Can be difficult to detect
  • Patients may lack insight
  • May not seek help feel unworthy

10
Ten key symptoms of depression
  • Depressed mood (forgt2weeks)
  • 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 (eg.early morning waking)
  • Appetite and weight change (usually lost)

11
STRESS
  • Term used in different ways
  • To indicate presence of stressors
  • 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

12
Life events scale
13
Somatisation
  • Somatisation has been defined as the expression
    of personal and social distress in an idiom of
    bodily complaints, with medical help seeking

14
Common !
  • In general medical practice,somatisation
    associated with psychiatric illness accounts for
    20 - 30 of all consultations
  • Higher in specialist clinics (50 or more)

15
Why the mouth ?
Sensory cortex
16
Theoretically,every disease is
psychosomatic,since emotional factors influence
all body processes through nervous and humoral
pathways
Franz 1950
17
PAIN
  • Pain is an unpleasant sensory and emotional
    experience associated with actual or potential
    tissue damage or described in terms of such
    damage
  • - pain is always subjective -

Int. Assoc. for the Study of Pain
18
PAIN
  • Pain is a complex sensation
  • Pain can cause considerable distress
  • chicken and egg situation
  • Dental pain can be difficult to diagnose
  • Beware of referred pain (sinuses,cervical
    spine,heart etc.)

19
KEY QUESTIONS
  • Is the pain present every day ?
  • What is a normal day like ?
  • How severe is the pain ? (score 0 10)

20
Rules of thumb !
  • Dental pain gets better or worse !
  • Chronic pain is rarely dental
  • If an experienced dentist feels the pain is not
    dental they are most often right

21
Assessment tools
  • Visual analogue scale

/
0
10
cm
No pain
Severe pain
- Verbal rating scale
Eg. How are things at present ?
0 could not be better
10 could not be worse
22
Orofacial pain conditions
  • Atypical facial pain
  • Atypical odontalgia
  • Oral dysaesthesia
  • Phantom bite syndrome
  • (TMD)
  • Syndrome of bizarre oro-facial symptoms

23
Atypical facial pain
  • Middle aged or older
  • Mainly female
  • Constant pain / discomfort
  • Poorly localised
  • May cross midline
  • Does not waken patient from sleep
  • Lack objective signs
  • Investigations (-ve)
  • Other symptoms (headaches,IBS,backache etc.)

24
Atypical facial pain
  • Demand physical treatment
  • Often do not accept psychological explanation
  • May have seen several specialists/practitioners
  • May be obsessed with symptoms

25
Management
  • History
  • Exclude organic disease
  • HAD scale
  • Life events counselling
  • medication / referral

26
Role of the dental practitioner
  • Explanation of these common conditions
  • Allow patients to express their concerns and
    beliefs as to what is happening
  • Reassure re. cancer phobia
  • Reduce fear of the need for surgery
  • Explanation of parafunction
  • To refer appropriately

27
Role of psychologist/psychiatrist
  • Detailed history
  • Explore connections to life events
  • Assess for psych disorders (depression)
  • Minimise iatrogenesis
  • Treat medication (antidepressants)
  • Treat psychological (CBT, CPN)
  • Treat social (support, links)
  • Liaise GDP, GMP, other specialists

28
Body dysmorphic disorder
  • An obsessive concern about a body part or
    appearance
  • Will seek physical intervention
  • Unlikely to be pleased with results and demand
    further treatment
  • May become depressed
  • Will not accept a psychological explanation

29
Wrong !
  • The doing anything is better than doing nothing
    approach this confirms the patients belief of a
    disease that is non-existent
  • Beware of litigation !

30
The scream
Edvard Munch 1863-1944
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