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_________________________________________________________REVIEW ARTICLE

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

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: Most of these patients also have


temporomandibular joint dysfunction and
MDD is currently ranked as the fourth most burning mouth syndrome. Caries is high due
common cause of disability and premature to poor diet, high sugar intake. In patients
death in the world by the World Health with substance abuse disorder there is an
Organization[12]. The prevalence rate is 5 to incidence of periodontal disease, due to
9% for women and 2 to 3% for men[1,13]. negligence and high incidence of smoking.
MDD is twice as common in adolescent and Trauma and dentofacial injury are common
adult females as in adolescent and adult and often untreated.
males[1].
Fear, anxiety and dental phobia are
People are most likely to suffer from their significant factors which influence
first depressive episode between the ages of acceptance of dental care. A number of
30 and 40, and there is a second, smaller factors such as mood, motivation, self
peak of incidence between ages 50 and 60. esteem, ability to think logically, accept and
understand the treatment plan, and ability to
The propensity to develop MDD is 40% co-operate with dental treatment may also
genetic and 60% environmental. affect the acceptance of the dental treatment.
Neurological disorders such as multiple
sclerosis, Parkinsons disease, stroke and The presence of pathogenic bacteria
head injury also are associated with a higher colonization can be caused by impaired
frequency of depression. immune system functioning related to
depression.
People with chronic diseases like coronary
artery disease and patients with cancer are at Depression is also believed to be associated
high risk of developing MDD with the with decreased metabolism of serotonin,
prevalence rate 25% to 40%. Approximately which in turn is associated with a tendency
30% people with MDD develop a substance to consume more carbohydrates, which
abuse disorder (that is, alcohol, illicit drugs) provides favorable conditions for aciduric
within their lifetime. bacteria to grow. A high count of these
bacteria causes the development and
Dental Consequences of Depression: progression of dental caries and periodontal
abscess.
The most commonly identified dental
implications of depression are reciprocal Treatment for MDD usually includes
relationship between chronic facial pain and pharmacological or psychotherapeutic
depression with studies showing rates of intervention, or both. Antidepressant
41% to 78%. Decreased energy and medications like selective serotonin reuptake
motivation associated with depression may inhibitors (SSRI), atypical antidepressants,
have a detrimental effect on oral hygiene tricyclic antidepressants (TCA) and
habits] and compliance with treatment monoamine oxidase inhibitors (MAOI) are
recommendations. been used to treat MDD, each with varying
dental related side effects, like xerostomia,
Oral symptoms may be the first or only dysgeusia, stomatitis, glossitis, sialadenitis,
manifestation of a MDD like facial pain, gingivitis, edema and discoloration of the
preoccupation with dentures, excessive tongue ( Table 1).
palatal erosion, or self inflicted injury and
enamel erosion is also reported in sufferers
of both anorexia and bulimia.

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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- isoenzymes needed to adequately metabolize


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


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Journal of Innovative Dentistry, Vol 1, Issue 3, Sept-December 2011