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Dental Consequences and Management in Patients with

Major Depressive Disorder
Verma A.1, Yadav S.2, Sachdeva A.3

Abstract:

Depression presents cognitive symptoms that can impact dental health and treatment.
Problems may arise from depressive symptoms, physiological consequences of depression, or
from side effects of antidepressant medication. Physiological consequences of depression
may lead to poor dental health due to xerostomia, cariogenic diet, and impaired immune
functioning contributing to dental caries, oral infection and other dental problems.
The role of dental professionals is to recognize a depressive condition, be familiar with the
patients medical history, current medications, depression related possible dental problems,
be aware of the alteration in the dental treatment planning and possibly facilitate an
appropriate referral for evaluation of the depressive symptoms.

Keywords: Major depressive disorder; Anti-depressants; Dental management.

Introduction:

alterations in appetite; insomnia or early

Major depressive disorder (MDD)
also known as unipolar depression is a
psychiatric illness of at least two weeks
duration during which the patient
experiences dysphoria (depressed mood,
sad, hopeless, irritable, anxious),
accompanied by low self-esteem, and
by loss of interest or pleasure in normally
enjoyable activities[1]. Suicide is the most
serious outcome of MDD, with 7% of men
and 1% of women committing suicide[2,3]
Depression is a major cause
of morbidity worldwide[4]. In most countries
the number of people who would suffer
from depression during their lives fall within
812% range[5,6]. Family member or patient
himself may note
awakening; agitation; slowed speech and
body movements (psychomotor retardation);
and an impaired ability to think, concentrate
or make decisions[1,7].
The onset of the disorder varies, with
symptoms developing over days to weeks.
Untreated episodes typically last six months
or longer. Eventually, the episode ends with
a complete remission of symptoms in about
70% of patients[8-11].
Our aim is to recognize patients with MDD,
make informed referrals to psychiatrist for
the diagnosis and treatment, and to offer
these patients complete dental treatment.

Correspondence: Dr. Ajay Verma, Reader, Deptt. of Oral & Maxillofacial Surgery, PDM Dental College & Research
Institute, Bahadurgarh-124507, Haryana, India, Email drajayverma05@yahoo.co.in, Tel. no. +91-9896003101.

1
Reader, 2Professor 3Lecturer, Deptt. of Oral & Maxillofacial Surgery, PDM Dental College & Research Institute,
Bahadurgarh-124507, Haryana, India.

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Incidence and Prevalence:
MDD is currently ranked as the fourth most
common cause of disability and premature
death in the world by the World Health
Organization[12]. The prevalence rate is 5 to
9% for women and 2 to 3% for men[1,13].
MDD is twice as common in adolescent and
adult females as in adolescent and adult
males[1].
People are most likely to suffer from their
first depressive episode between the ages of
30 and 40, and there is a second, smaller
peak of incidence between ages 50 and 60.
The propensity to develop MDD is 40%
genetic and 60% environmental.
Neurological disorders such as multiple
sclerosis, Parkinsons disease, stroke and
head injury also are associated with a higher
frequency of depression.
People with chronic diseases like coronary
artery disease and patients with cancer are at
high risk of developing MDD with the
prevalence rate 25% to 40%. Approximately
30% people with MDD develop a substance
abuse disorder (that is, alcohol, illicit drugs)
within their lifetime.
Dental Consequences of Depression:
The most commonly identified dental
implications of depression are reciprocal
relationship between chronic facial pain and
depression with studies showing rates of
41% to 78%. Decreased energy and
motivation associated with depression may
have a detrimental effect on oral hygiene
habits] and compliance with treatment
recommendations.
Oral symptoms may be the first or only
manifestation of a MDD like facial pain,
preoccupation with dentures, excessive
palatal erosion, or self inflicted injury and
enamel erosion is also reported in sufferers
of both anorexia and bulimia.
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Most of these patients also have
temporomandibular joint dysfunction and
burning mouth syndrome. Caries is high due
to poor diet, high sugar intake. In patients
with substance abuse disorder there is an
incidence of periodontal disease, due to
negligence and high incidence of smoking.
Trauma and dentofacial injury are common
and often untreated.
Fear, anxiety and dental phobia are
significant factors which influence
acceptance of dental care. A number of
factors such as mood, motivation, self
esteem, ability to think logically, accept and
understand the treatment plan, and ability to
co-operate with dental treatment may also
affect the acceptance of the dental treatment.
The presence of pathogenic bacteria
colonization can be caused by impaired
immune system functioning related to
depression.
Depression is also believed to be associated
with decreased metabolism of serotonin,
which in turn is associated with a tendency
to consume more carbohydrates, which
provides favorable conditions for aciduric
bacteria to grow. A high count of these
bacteria causes the development and
progression of dental caries and periodontal
abscess.
Treatment for MDD usually includes
pharmacological or psychotherapeutic
intervention, or both. Antidepressant
medications like selective serotonin reuptake
inhibitors (SSRI), atypical antidepressants,
tricyclic antidepressants (TCA) and
monoamine oxidase inhibitors (MAOI) are
been used to treat MDD, each with varying
dental related side effects, like xerostomia,
dysgeusia, stomatitis, glossitis, sialadenitis,
gingivitis, edema and discoloration of the
tongue ( Table 1).
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Table 1: Dental related side effects Dental Treatment of Patients with
Antidepressant Dental related side Depression:
medications effects
Lack of interest and low self esteem
associated with MDD are factors that
Selective serotonin Xerostomia, contribute to inadequate self-care and
reuptake inhibitors dysgeusia, regular dental attendance. Many patients
stomatitis, who are receiving anti-depression treatment
gingivitis, glossitis, may be reluctant to admit this because of the
sialadenitis, perceived stigma associated with mental
discolored tongue, illness. Oral health and dental management
tongue edema, is also compromised by medical problems
bruxism. associated with alcohol abuse, drug
addiction, smoking, and stress as well as
Xerostomia, prescribed anti-depressant medication.
Atypical
antidepressants dysgeusia, Depressed patients may be uncooperative
stomatitis, and irritable during dental treatment, appear
gingivitis, glossitis, unappreciative and have numerous
sialadenitis, complaints that are inconsistent with
discolored tongue, objective findings.
tongue edema,
The key to reducing the barrier to oral health
monoliasis,
care is to establish effective and ongoing
periodontal
communication between the patient, dental
abscesses, oral
team, psychiatrist. Consent for treatment
ulcers, sinusitis,
should be obtained following professional
bruxism, and
guidelines. Before a patient begins dental
halitosis.
treatment, the dentist should consult with his
or her psychiatrist (after informing the
patient). Information requested should
Tricyclic Xerostomia, include the patients current psychological
antidepressants dysgeusia, status and current psychotropic medication
stomatitis, regimen. Treatment planning, which is
sialadenitis, tongue patient centered, realistic and flexible, and
edema, cheilitis. which takes into account the problems
associated with depression is more likely to
Monoamine oxidase Xerostomia be acceptable and successful. A small
inhibitors number of patients will require the use of
sedation techniques or general anesthesia.
Xerostomia has a significant impact on oral Patients with a history of alcohol abuse
health and increases the risk of dental caries, should undergo liver function tests, a
periodontal disease, oral infections such complete blood cell count and a coagulation
candidiasis and in extreme cases may cause profile. To overcome such barriers and
acute inflammation of salivary glands. This obtain necessary information, the dentist
may present as the difficulty with speech, should exhibit a supportive, nonjudgmental
chewing, swallowing, poor denture attitude.
tolerance, problems with retention and
stability of dentures or denture trauma.

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Dental team should be aware of-
a) Depression and its symptoms.
b) Social and behavioral aspects of
MDD.
c) Dental related side effects of
medications and drug interactions.
d) Dental management.
e) Coping with aggression and
handling stress.
Preventive dental education is vital for these
patients and their families. Information
regarding proper tooth brushing and flossing
methods should be given. Artificial salivary
products are prescribed for patients with
xerostomia. Dental treatment should include
sub gingival scaling, root planing and
curettage, caries control and restorative
treatment. Profound local anesthesia is
mandatory to perform these procedures
adequately in depressed and anxious
patients.
In patients receiving TCAs, precaution is
taken when administering local anesthetics
containing adrenergic vasoconstrictors.
TCAs block the reuptake of these
vasoconstrictors and block muscarinic and
1-adrenergic receptors, thereby directly
depressing the heart. Epinephrine
moderately interacts with TCAs but can be
used, in a dosage not to exceed 0.04
milligrams (the equivalent of four cartridges
of 1:200,000 epinephrine) and with careful
aspiration to avoid intravascular
administration. Levonordefrin adversely
interacts with TCAs, resulting in dramatic
increases in systolic blood pressure and
cardiac dysrrhythmias.
Adverse interactions between SSRIs and
some medications used in dentistry may
occur because these antidepressants inhibit
certain metabolic pathways. Specifically,
SSRIs inhibit the cytochrome P-450
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ARTICLE
isoenzymes needed to adequately metabolize
codeine, benzodiazepines, erythromycin and
carbamazepine. Therefore, these dental
therapeutic agents should be used cautiously
and in reduced dosages.
TCAs may potentiate the depressant effects
of sedative-hypnotics, narcotics and
barbiturates, which can cause severe
respiratory depression. Care should also be
taken when prescribing acetaminophen
because of its ability to increase TCA levels.
Patients being treated with MAOIs can
receive local anesthetic solutions containing
epinephrine or levonordefrin, as these drugs
do not potentiate their cardiac effects.
However, narcotic analgesics for these
patients should be avoided because of a
potentially toxic interaction in which severe
hyperthermia, hypertension and tachycardia
may develop.
Dental professionals are recommended to
perform a clinical examination and oral
prophylaxis at three-month follow-up visits
and fluoride gel application. Any defects in
the natural dentition or in prosthesis should
also be corrected during the visits. Patients
may experience enhanced self-esteem as a
result of dental treatment, which may
contribute to the psychotherapeutic aspect of
management.
Conclusion:
Major depression is a common disorder that
has been demonstrated to affect physical as
well as mental health, with an increasing
prevalence among young adults. It may be
associated with a disinterest in performing
appropriate oral hygiene techniques, a
cariogenic diet, diminished salivary flow,
rampant dental decay, advanced periodontal
disease, and oral dysesthesias. Many
medications used to treat the disease
magnify the xerostomia and are associated
with dental related side effects. We must
emphasize that appropriate dental
management should be done including
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preventive dental education programme, the Comorbidity Survey Replication

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