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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.

The members of University of Medicine and Pharmacy Iuliu Hatieganu have

contributed immensely to my personal and professional time at the Faculty of Medicine, Cluj-
Napoca. They have been a source of friendships as well as good advice and collaboration.

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.




JULY 2013

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Chapter I

1.1 Common metal illness in relation with dentistry................6

1.2 Classification of mental disorder........................................9
1.2.1 Depression................................................................10
1.2.2 Schizophrenia...........................................................13
1.2.3 Dementia..................................................................18
1.2.4 Mania.......................................................................20
1.2.5 Anxiety disorder......................................................22
1.2.6 Drug abuse...............................................................24

Chapter II

2.1 Description of the principal structure of the tooth............27

Chapter III

3.1 Particularities of mental patients in dentistry....................38


Chapter 1. Objectives of the study...........................................42

Chapter 2. Material and methods.............................................43

Chapter 3. Results...................................................................49

3.1 Evaluation of general and mental health of patients..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



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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.

There is a complex interrelationship between socio-economic factors, illness, its

treatment and oral health. Cost and fear are the most commonly cited barriers to dental care,
illness whether physical or mental may lead to deterioration in self care, and oral care may
already have a low priority. Its very important to ensure that individuals have sufficient
information and support in order to live independent lives including oral care and access to
appropriate dental care.

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.

In general patients with mental illness tends to receive unfavorable treatment in

comparision to the general population. They receive less adequate dental treatment in almost
all aspects and the design of prosthetic appliances does not take into consideration their
special needs. Possible cause for this phenomenon include social and medical factors. Social-
economic background is generally worse compared to the general population. The stigma of
the mental illness may affect dentist themselves. They try and choose treatment options that
are quick and simple, such as tooth extraction foregoing more complicated procedure.

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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1.1 Common mental illness in relation with dentistry

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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.

1.2 Classification of mental disorders

The classification of mental disorders, also known as psychiatric nosology

or taxonomy, is a key aspect of psychiatry and other mental health professions and an
important issue for people who may be diagnosed. There are currently two widely established
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systems for classifying mental disordersChapter V of the International Classification of
Diseases (ICD-10) produced by the World Health Organization (WHO) and the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric
Association (APA) [12].

The International Classification of Diseases (ICD) is an international standard

diagnostic classification for a wide variety of health conditions. Chapter V focuses on
"mental and behavioural disorders" and consists of 10 main groups:

F0: Organic, including symptomatic, mental disorders

F1: Mental and behaviour disorders due to use of psychoactive substances

F2: Schizophrenia, schizotypal and delusional disorders

F3: Mood [affective] disorders

F4: Neurotic, stress-related and somatoform disorders

F5: Behavioural syndromes associated with physiological disturbances and physical


F6: Disorders of personality and behaviour in adult persons

F7: Mental retardation

F8: Disorders of psychological development

F9: Behaviour and emotional disorders with onset usually occurring in childhood and

In addition, a group of "unspecified mental disorders".

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

1.2. 1 Depression

Major depressive disorder (MDD) (also known as clinical depression, major

depression, unipolar depression, unipolar disorder or recurrent depression in the case of
repeated episodes) is a mental disorder characterized by episodes of all-encompassing low
mood accompanied by low self-esteem and loss of interest or pleasure in normally enjoyable
activities. This cluster of symptoms (syndrome) was named, described and classified as one
of the mood disorders in the 1980 edition of the American Psychiatric Association s
diagnostic manual .
Major depressive disorder is a disabling condition that adversely affects a
person's family, work or school life, sleeping and eating habits, and general health. In the
United States, around 3.4% of people with major depression commit suicide, and up to 60%
of people who commit suicide had depression or another mood disorder [13] .
The diagnosis of major depressive disorder is based on the patient's self-
reported experiences, behavior reported by relatives or friends, and a mental status
examination. There is no laboratory test for major depression, although physicians generally
request tests for physical conditions that may cause similar symptoms. The most common
time of onset is between the ages of 20 and 30 years, with a later peak between 30 and 40

Symptoms and signs

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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.


The biopsychosocial model proposes that biological, psychological, and social

factors all play a role in causing depression. The diathesisstress model specifies that
depression results when a preexisting vulnerability, or diathesis, is activated by stressful life
events. The preexisting vulnerability can be either genetic, implying an interaction between
nature and nurture, or schematic, resulting from views of the world learned in childhood.
Depression may be directly caused by damage to the cerebellum as is seen in cerebellar
cognitive affective syndrome .These interactive models have gained empirical support. For
example, researchers in New Zealand took a prospective approach to studying depression, by
documenting over time how depression emerged among an initially normal cohort of people.

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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].

Drug and alcohol use

Very high levels of substance abuse occur in the psychiatric population,

especially alcohol, sedatives and cannabis. Depression and other mental health problems can
have a substance induced cause; making a differential or dual diagnosis regarding whether
mental ill-health is substance related or not or co-occurring is an important part of a
psychiatric evaluation. According to the DSM-IV, a diagnosis of mood disorder cannot be
made if the cause is believed to be due to "the direct physiological effects of a substance";
when a syndrome resembling major depression is believed to be caused immediately by
substance abuse or by an adverse drug reaction, it is referred to as, "substance-induced mood
disturbance" [16]. Alcoholism or excessive alcohol consumption significantly increases the
risk of developing major depression. Like alcohol, the benzodiazepines are central nervous
system depressants; this class of medication is commonly used to treat insomnia, anxiety, and
muscular spasms. Similar to alcohol, benzodiazepines increase the risk of developing major
depression. This increased risk of depression may be due in part to the adverse or toxic
effects of sedative-hypnotic drugs including alcohol on neurochemistry, such as decreased
levels of serotonin and norepinephrine, or activation of immune mediated inflammatory
pathways in the brain. Chronic use of benzodiazepines also can cause or worsen depression,
or depression may be part of a protracted withdrawal syndrome. About a quarter of people
recovering from alcoholism experience anxiety and depression which can persist for up to 2
years. Methamphetamine abuse is also commonly associated with depression.

DSM-IV-TR and ICD-10 criteria

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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.


The three most common treatments for depression are psychotherapy,

medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice for
people under 18, while electroconvulsive therapy is used only as a last resort. Care is usually
given on an outpatient basis, whereas treatment in an inpatient unit is considered if there is a
significant risk to self or others. Treatment options are much more limited in developing
countries, where access to mental health staff, medication, and psychotherapy is often
difficult. Development of mental health services is minimal in many countries; depression is
viewed as a phenomenon of the developed world despite evidence to the contrary, and not as
an inherently life-threatening condition. Physical exercise is recommended for management
of mild depression, but it has only a moderate, statistically insignificant effect on symptoms
in most cases of major depressive disorder .

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Chart nr 1 Zoloft (sertraline HCl) pills


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

Schizophrenia is a mental disorder characterized by a breakdown of thought

processes and by a deficit of typical emotional responses. Common symptoms include
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auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking,
and it is accompanied by significant social or occupational dysfunction. The disorder is
thought mainly to affect cognition, but it also usually contributes to chronic problems with
behavior and emotion. People with schizophrenia are likely to have additional (comorbid)
conditions, including major depression and anxiety disorders; the lifetime occurrence of
substance use disorder is almost 50%. Social problems, such as long-term unemployment,
poverty, and homelessness are common. The average life expectancy of people with the
disorder is 12 to 15 years less than those without, the result of increased physical health
problems and a higher suicide rate (about 5%) [18].


A person diagnosed with schizophrenia may experience hallucinations (most reported

are hearing voices), delusions (often bizarre or persecutory in nature), and disorganized
thinking and speech. The latter may range from loss of train of thought, to sentences only
loosely connected in meaning, to incoherence known as word salad in severe cases. Social
withdrawal, sloppiness of dress and hygiene, and loss of motivation and judgment are all
common in schizophrenia. There is often an observable pattern of emotional difficulty, for
example lack of responsiveness. Impairment in social cognition is associated with
schizophrenia, as are symptoms of paranoia; social isolation commonly occurs. Difficulties in
working and long-term memory, attention, executive functioning, and speed of processing
also commonly occur. In one uncommon subtype, the person may be largely mute, remain
motionless in bizarre postures, or exhibit purposeless agitation, all signs of catatonia. About
30% to 50% of people with schizophrenia do not have insight, in other words, they do not
accept their condition or its treatment [19].


A combination of genetic and environmental factors play a role in the development of

schizophrenia. People with a family history of schizophrenia who suffer a transient psychosis
have a 2040% chance of being diagnosed one year later. Estimates of heritability vary
because of the difficulty in separating the effects of genetics and the environment. The
greatest risk for developing schizophrenia is having a first-degree relative with the disease
(risk is 6.5%); Environmental factors associated with the development of schizophrenia
include the living environment, drug use and prenatal stressors. Parenting style seems to have
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no major effect, although people with supportive parents do better than those with critical or
hostile parents. Living in an urban environment during childhood or as an adult has
consistently been found to increase the risk of schizophrenia by a factor of two, even after
taking into account drug use, ethnic group, and size of social group. Other factors that play an
important role include social isolation and immigration related to social adversity, racial
discrimination, family dysfunction, unemployment, and poor housing conditions [20].


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.

Schizophrenia is diagnosed based on criteria in either the American Psychiatric

Association's Diagnostic and Statistical Manual of Mental Disorders, version DSM-IV-TR, or
the World Health Organization's International Statistical Classification of Diseases and
Related Health Problems, the ICD-10. These criteria use the self-reported experiences of the
person and reported abnormalities in behavior, followed by a clinical assessment by a mental
health professional. Symptoms associated with schizophrenia occur along a continuum in the
population and must reach a certain severity before a diagnosis is made.

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

o Disorganized speech, which is a manifestation of formal thought disorder

o Grossly disorganized behavior (e.g. dressing inappropriately, crying

frequently) or catatonic behavior

o Negative symptoms: Blunted affect (lack or decline in emotional response),

alogia (lack or decline in speech), or avolition (lack or decline in motivation)

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
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).


The primary treatment of schizophrenia is antipsychotic medications, often in

combination with psychological and social supports. Hospitalization may occur for severe
episodes either voluntarily or (if mental health legislation allows it) involuntarily. Long-term
hospitalization is uncommon since deinstitutionalization beginning in the 1950s, although it
still occurs. Community support services including drop-in centers, visits by members of a
community mental health team, supported employment and support groups are common.

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Some evidence indicates that regular exercise has a positive effect on the physical and mental
health of those with schizophrenia.


Schizophrenia is a major cause of disability, with active psychosis ranked as

the third-most-disabling condition after quadriplegia and dementia and ahead of paraplegia
and blindness. Approximately three-fourths of people with schizophrenia have ongoing
disability with relapses and 16.7 million people globally are deemed to have moderate or
severe disability from the condition. Some people do recover completely and others function
well in society. Most people with schizophrenia live independently with community support.

1.2.3 Dementia

Dementia is a serious loss of global cognitive ability in a previously

unimpaired person, beyond what might be expected from normal aging. It may be static, the
result of a unique global brain injury, or progressive, resulting in long-term decline due to
damage or disease in the body. Dementia can be classified as either reversible or irreversible,
depending upon the etiology of the disease. Fewer than 10% of cases of dementia are due to
causes that may be reversed with treatment. Some of the most common forms of dementia
are: Alzheimer's disease, vascular dementia, fronto-temporal dementia, semantic dementia
and dementia with Lewy bodies [21].

Signs and symptoms

Dementia is not merely a problem of memory. It reduces the ability to learn,

reason, retain or recall past experience and there is also loss of patterns of thoughts, feelings
and activities. Additional mental and behavioral problems often affect people who have
dementia, and may influence quality of life, caregivers, and the need for institutionalization.
As dementia worsens individuals may neglect themselves and may become disinhibited and

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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].


Fixed cognitive impairment

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].


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.


Except for some types of this disease, there is no cure. Cholinesterase

inhibitors are often used early in the disease course. Cognitive and behavioral interventions
may also be appropriate. Educating and providing emotional support to the caregiver (or
carer) is of importance as well elderly care [24].

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1.2.4 . Mania

Mania is a state of abnormally elevated or irritable mood, arousal, and/or

energy levels. In a sense, it is the opposite of depression. Mania is a necessary symptom for
certain psychiatric diagnoses. In addition to mood disorders, persons may exhibit manic
behaviour because of drug intoxication (notably stimulants, such as cocaine and
methamphetamine), medication side effects (notably steroids and SSRIs), and malignancy.
But mania is most often associated with bipolar disorder, where episodes of mania may
alternate with episodes of major depression. Gelder, Mayou, and Geddes (2005) [ 25] suggest
that it is vital that mania be predicted in the early stages because otherwise the patient
becomes reluctant to comply to the treatment. The criteria for bipolar disorder do not include
depressive episodes, and the presence of mania in the absence of depressive episodes is
sufficient for a diagnosis. Regardless, those who never experience depression also experience
cyclical changes in mood. These cycles are often affected by changes in sleep cycle (too
much or too little), diurnal rhythms, and environmental stressors.

Signs and symptoms

A manic episode is defined in the American Psychiatric Association's

diagnostic manual as a period of seven or more days (or any period if admission to hospital is
required) of unusually and continuously effusive and open elated or irritable mood, where the
mood is not caused by drugs/medication or a medical illness (e.g., hyperthyroidism), and is
causing obvious difficulties at work or in social relationships and activities, or requires
admission to hospital to protect the person or others, or the person is suffering psychosis. To
be classed as a manic episode, while the disturbed mood is present at least three (or four if
only irritability is present) of the following must have been consistently prominent: grand or
extravagant style, or expanded self-esteem; pressured speech; reduced need of sleep (e.g.
three hours may be sufficient); talks more often and feels the urge to talk longer; ideas flit
through the mind in quick succession, or thoughts race and preoccupy the person; over
indulgence in enjoyable behaviours with high risk of a negative outcome (e.g., extreme
energy, over positive mood, extravagant shopping, sexual adventures or improbable
commercial schemes) [26]. If the person is concurrently depressed, they are said to be having a
mixed episode. The World Health Organization's classification system defines a manic
episode as one where mood is higher than the person's situation warrants and may vary from

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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.


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.


Acute mania in bipolar disorder is typically treated with mood stabilizers or

antipsychotic medication. Note that these treatments need to be prescribed and monitored
carefully to avoid harmful side-effects such as neuroleptic malignant syndrome with the
antipsychotic medications. It may be necessary to temporarily admit the patient involuntarily
until the patient is stabilized. Antipsychotics and mood stabilizers help stabilize mood of
those with mania or depression.

1.2.5 Anxiety disorder

Anxiety disorder is an umbrella term that covers several different forms of a

type of common psychiatric disorder characterized by excessive rumination, worrying,
uneasiness, apprehension and fear about future uncertainties either based on real or imagined
events, which may affect both physical and psychological health. There are numerous
psychiatric and medical syndromes which may mimic the symptoms of an anxiety disorder
such as hyperthyroidism which may be misdiagnosed as generalized anxiety disorder. The

21 | P a g e
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

The single largest category of anxiety disorders is that of phobic disorders,

which includes all cases in which fear and anxiety is triggered by a specific stimulus or
situation. Between 5% and 12% of the population worldwide suffer from phobic disorders.
Sufferers typically anticipate terrifying consequences from encountering the object of their
fear, which can be anything from an animal to a location to a bodily fluid to a particular
situation. Sufferers understand that their fear is not proportional to the actual potential danger
but still are overwhelmed by the fear [28].

B2. Panic disorder

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

Obsessivecompulsive disorder (OCD) is a type of anxiety disorder primarily

characterized by repetitive obsessions (distressing, persistent, and intrusive thoughts or
images) and compulsions (urges to perform specific acts or rituals). It affects roughly around
3% of the population worldwide. The OCD thought pattern may be likened to superstitions
insofar as it involves a belief in a causative relationship where, in reality, one does not exist.
Often the process is entirely illogical; for example, the compulsion of walking in a certain
pattern may be employed to alleviate the obsession of impending harm.



Low levels of GABA, a neurotransmitter that reduces activity in the central

nervous system, contribute to anxiety. A number of anxiolytics achieve their effect by
modulating the GABA receptors.

D4. Stress

Anxiety disorders can arise in response to life stresses such as financial

worries or chronic physical illness. Somewhere between 4% and 10% of older adults are
diagnosed with anxiety disorder, a figure that is probably an underestimate due to the
tendency of adults to minimize psychiatric problems or to focus on their physical
manifestations. Anxiety is also common among older people who have dementia. On the
other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors
misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac
arrhythmia) as signs of anxiety [30].


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.

Treatment options available include lifestyle changes; psychotherapy,

especially cognitive behavioral therapy; and pharmaceutical therapy. Education, reassurance
and some form of cognitive-behavioral therapy should almost always be used in treatment.
Research has provided evidence for the efficacy of two forms of treatment available for social
phobia: certain medications and a specific form of short-term psychotherapy called cognitive-
behavioral therapy (CBT), the central component being gradual exposure therapy. Self-help
books can contribute to the treatment of people with anxiety disorders [31].

1.2.6 Drug abuse

Drug abuse, is a patterned use of a substance (drug) in which the user

consumes the substance in amounts or with methods neither approved nor supervised by
medical professionals. Substance abuse/drug abuse is not limited to mood-altering or psycho-
active drugs. If an activity is performed using the objects against the rules and policies of the
matter (as in steroids for performance enhancement in sports), it is also called substance
abuse. Therefore, mood-altering and psychoactive substances are not the only types of drugs
abused. Using illicit drugs narcotics, stimulants, depressants (sedatives), hallucinogens,
cannabis, even glues and paints, are also considered to be classified as drug/substance abuse.
Substance abuse is a form of substance-related disorder [32].

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

Drug abuse, including alcohol and prescription drugs can induce

symptomatology which resembles mental illness. Drug abuse makes central nervous system
(CNS) effects, which produce changes in mood, levels of awareness or perceptions and
sensations. Most of these drugs also alter systems other than the CNS. Some of these are
often thought of as being abused. Some drugs appear to be more likely to lead to uncontrolled
use than others [33].


Many of the genetic, psychological, and environmental factors identified as

potentially contributing to the development of substance abuse behaviors by multiple-
generation by non-recent immigrants and refugees are similar for more recent immigrants and
refugees. Heritable genetic, cognitive, and temperamental characteristics may signify
increased risk or protective factors for biological family members. Psychological theories,
such as the psychoanalytic, behavioral, cognitive, and social learning models may help to
explain the role of environment in shaping substance abuse behaviors and patterns.
Sociocultural models focusing on family interactions, peer influences, and social
environments may describe the interpersonal mechanisms partially leading to substance abuse



From the applied behavior analysis literature, behavioral psychology, and

from randomized clinical trials, several evidenced based interventions have emerged:
behavioral marital therapy, motivational, interviewing, community reinforcement approach,

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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.


Pharmacological therapy - A number of medications have been approved for

the treatment of substance abuse. These include replacement therapies such as buprenorphine
and methadone as well as antagonist medications like disulfiram and naltrexone in either
short acting, or the newer long acting form. Several other medications, often ones originally
used in other contexts, have also been shown to be effective including bupropion and


1. Describe the principal structure of a tooth

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

26 | P a g e
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.


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Chart nr 3 Section of a human molar


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].

Enamel's primary mineral is hydroxylapatite, which is a crystalline calcium

phosphate. The large amount of minerals in enamel accounts not only for its strength but also
for its brittleness. Dentin, which is less mineralized and less brittle, compensates for enamel
and is necessary as a support. Unlike dentin and bone, enamel does not contain collagen.
Instead, it has two unique classes of proteins called amelogenins and enamelins. While the
role of these proteins is not fully understood, it is believed that they aid in the development of
enamel by serving as framework support among other functions.
28 | P a g e

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.

Dentin is a mineralized connective tissue with an organic matrix of collagenous

proteins. Dentin has microscopic channels, called dentinal tubules, which radiate outward
through the dentin from the pulp cavity to the exterior cementum or enamel border. The
diameter of these tubules range from 2.5 m near the pulp, to 1.2 m in the midportion, and
900 nm near the dentino-enamel junction [37]. Although they may have tiny side-branches, the
tubules do not intersect with each other. Their length is dictated by the radius of the tooth.
The three dimensional configuration of the dentinal tubules is genetically determined.


Cementum is a specialized bone like substance covering the root of a tooth. It is

approximately 45% inorganic material (mainly hydroxyapatite), 33% organic material
(mainly collagen) and 22% water. Cementum is excreted by cementoblasts within the root of
the tooth and is thickest at the root apex. Its coloration is yellowish and it is softer than either
dentin or enamel. The principal role of cementum is to serve as a medium by which the
periodontal ligaments can attach to the tooth for stability. At the cementoenamel junction, the
cementum is acellular due to its lack of cellular components, and this acellular type covers at
least of the root. The more permeable form of cementum, cellular cementum, covers about
of the root apex [38].


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
29 | P a g e
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

The periodontal ligament is a specialized connective tissue that attaches the

cementum of a tooth to the alveolar bone. This tissue covers the root of the tooth within the
bone. Each ligament has a width of 0.150.38mm, but this size decreases over time. The
functions of the periodontal ligaments include attachment of the tooth to the bone, support for
the tooth, formation and resorption of bone during tooth movement, sensation, and eruption.
The cells of the periodontal ligaments include osteoblasts, osteoclasts, fibroblasts,
macrophages, cementoblasts, and epithelial cell rests of Malassez. Consisting of mostly Type
I and III collagen, the fibers are grouped in bundles and named according to their location.
The groups of fibers are named alveolar crest, horizontal, oblique, periapical, and
interradicular fibers [40]. The nerve supply generally enters from the bone apical to the tooth
and forms a network around the tooth toward the crest of the gingiva. When pressure is
exerted on a tooth, such as during chewing or biting, the tooth moves slightly in its socket
and puts tension on the periodontal ligaments. The nerve fibers can then send the information
to the central nervous system for interpretation.

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

30 | P a g e
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].


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 is a biofilm consisting of large quantities of various bacteria that form on

teeth. If not removed regularly, plaque buildup can lead to periodontal problems such as
gingivitis. Given time, plaque can mineralize along the gingiva, forming tartar. The
microorganisms that form the biofilm are almost entirely bacteria (mainly streptococcus and
anaerobes), with the composition varying by location in the mouth. Streptococcus mutans is
the most important bacterium associated with dental caries [42].

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)

Chart nr 4 Advanced tooth decay on a premolar.

Dental caries (cavities), described as "tooth decay", is an infectious disease which

damages the structures of teeth. The disease can lead to pain, tooth loss, and infection. The
largest increases in the prevalence of caries have been associated with diet changes. Today,
caries remains one of the most common diseases throughout the world. In the United States,
dental caries is the most common chronic childhood disease, being at least five times more
common than asthma. Countries that have experienced an overall decrease in cases of tooth
decay continue to have a disparity in the distribution of the disease. Among children in the
United States and Europe, 6080% of cases of dental caries occur in 20% of the population

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

32 | P a g e
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.


Chart nr 5 An amalgam used as a restorative material in a tooth.

Destroyed tooth structure does not fully regenerate, although remineralization

of very small carious lesions may occur if dental hygiene is kept at optimal level. For the
small lesions, topical fluoride is sometimes used to encourage remineralization. For larger
lesions, the progression of dental caries can be stopped by treatment [ 44]. The goal of
treatment is to preserve tooth structures and prevent further destruction of the tooth.
Aggressive treatment, by filling, of incipient carious lesions, places where there is superficial
damage to the enamel, is controversial as they may heal themselves, while once a filling is
performed it will eventually have to be redone and the site serves as a vulnerable site for
further decay. A dental handpiece ("drill") is used to remove large portions of decayed
material from a tooth. A spoon, a dental instrument used to carefully remove decay, is
sometimes employed when the decay in dentin reaches near the pulp. Once the decay is
removed, the missing tooth structure requires a dental restoration of some sort to return the
tooth to function and aesthetic condition.Restorative materials include dental amalgam,
composite resin, porcelain, and gold. Composite resin and porcelain can be made to match
the color of a patient's natural teeth and are thus used more frequently when aesthetics are a
concern [45].
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Periodontal disease

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

While many different diseases affect the tooth-supporting structures, plaque-induced

inflammatory lesions make up the vast majority of periodontal diseases and have traditionally
been divided into two categories:

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

Features of the Initial Lesion:

Vasculitis of vessels subjacent to junctional epithelium

Increased migration of leukocytes into junctional epithelium

Extravascular presence of serum proteins, especially fibrin

Alteration of the most coronal portion of junctional epithelium

Loss of perivascular collagen

Features of the Early 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

Cytopathic alterations in resident fibroblasts

Preliminary proliferation of basal cells of junctional epithelium

Features of the Established Lesion:

Predominance of plasma cells without bone loss

Presence of extravascular immunoglobulins in the connective tissue and
junctional epithelium

Continuing loss of collagen

Proliferation, apical migration and lateral extension of the junctional

epithelium, with or without pocket formation

Features of the Advanced Lesion:

Extension of the lesion into alveolar bone, periodontal ligament with

significant bone loss
Continued loss of collagen

Cytopathic alterations in plasma cells in the absence of altered fibroblasts

Formation of periodontal pocketing

Conversion of bone marrow into fibrous connective tissue


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.


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

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
maintain an individual's vertical dimension of occlusion

along with the tongue and lips, allow for the proper pronunciation of various sounds

preserve and maintain the height of the alveolar ridge

cut, grind, and otherwise chew food


The etiology, or cause of edentulism, can be multifaceted. While the extraction

of non-restorable or non-strategic teeth by a dentist does contribute to edentulism, the
predominant cause of tooth loss in developed countries is periodontal disease. While the teeth
may remain completely decay-free, the bone surrounding and providing support to the teeth
may reabsorb and disappear, giving rise to tooth mobility and eventual tooth loss.


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

1. Particularities of mental patients in dentistry

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:

2. To determine the oral health status of institutionalized psychiatric patients in

Romania, Cluj.

3. To assess the treatment needs of institutionalized psychiatric patients in Romania,


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

38 | P a g e
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.

In another study made by Lynch U, Lazenbatt A, Freeman R, Lynch G, Neill EO,

they discover that patients with mental illness The study focused on 65 long stay patients in a
psychiatric hospital, mean length of time patients had been in the hospital was 25.6 years;
nine patients had been living in the hospital between 40 and 65 years. The study achieved a
response rate of 82% and identified that oral health of the psychiatric patients was generally
very poor, compared to the general population. Only one patient did not have calculus,
decayed or fractured teeth and 12 of the patients were endentate and there was a conspicuous
absence of health promoting behaviours amongst the patient group [50].

In another study made by Department of Preventive and Community Dentistry, College

of Dental Sciences, Davangere, Karnataka, India we understand that from 220 psychiatric
patients admitted in two general hospitals of Davangere during the period of one year were
included in the study. The oral health status was evaluated with respect to caries, oral
hygiene, and periodontal status. Of the 180 examined with the response rate of 81.8%. 58.3%
were males, mean age was 36.7 years, 57.8% had < 1 year of mental illness with a mean of
2.2 years, and 90% were self-sufficient. The multiple logistic regression analysis showed that
the mean DMFT (0.92) increased with age, duration of mental illness, and irregularity of oral
hygiene habits (P<0.001). Mean OHI-S score was 3.3 and multiple logistic regression
analysis showed that the mean OHI-S score increased with age (P<0.001). The multiple
logistic regression analysis showed that the CPI score increased with age, duration of mental
illness, and degree of helplessness (P<0.001). The findings of this study demonstrates low
caries prevalence, poor oral hygiene, and extensive unmet needs for dental treatment [51].

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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].

In another study in Sweden Annsofi Johannsen 2006 on periodontal state and

biochemical marker in relation to self reported anxiety, and to stress related affective disorder
severe enough to lead to long term sick leave, the following finding were made. In subjects
with signs of periodontal disease, self-reported anxiety was associated with worse gingival
inflammation, and smoking was associated with deeper pockets and more loss of attachment
in the anxious than in the non anxious group, in spite of the absence of biochemical markers
between the two groups. Patients on long term sick leave for stress related depression and
exhaustion disorder, diagnose by a psychiatric using diagnostic criteria had more dental
plaque and gingival inflammation, and more deep pockets than healthy patients [53].

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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.

The objectives of this paper are:

1. Identification characteristics of patients with mental illness;

2. The way and the type of treatment given to mental ill patients.

3. Monitor the evolution of treatments;

4. The importance of regular checkups by dentist and clinicians of patients needs.

42 | P a g e
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.

Exclusion criteria included uncooperative patients (aggressive), patients who were

subjected to periodic monitoring, patients who were about to be discharged from the clinic
after their treatment and finally patients who had positive diagnoses of the following diseases
(with HIV, hepatitis B, C, D and cancer).

The above group of patients were monitored and investigated over a period of one year:

1. Oral health of patient prior to initial treatment of mental illness;

2. Evolution of oral health of patients during their stay at the psychiatry hospitalized.

Examination of patients diagnosed with psychiatric illnesses included:

1. History - ill patient data reports

2. Physical exam - by inspection and palpation

3. Laboratory examinations - (periapical or dento alveolar radiography and OPT) stating

diagnosis and helps in choosing the most effective treatment measures.

A written patient consent was request from patient or their guidance before their inclusion
on the thesis.

Odontal diagnosis was based on clinical examination of dento maxillary units by

inspection, palpation, percussion and as laboratory tests as well as radiography (periapical,
dento alveolar or OPT). The diagnosis of periodontal gum disease was done by inspection,
palpation and determining tooth mobility. To calculate attachment loss a periodontal probe

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

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

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.

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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).

Chart nr 1 Distribution of patients according their age

Of all 52 patients, the distribution by sex of patients in experimental group comprised

18 men and 34 women (Chart 2).

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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

3.1 Evaluation of general and mental health of patients

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).

Chart nr 4 Distribution of patients according their general diseases

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

Distribution of patients by family history we found that 37 patients shows no

history(Chart nr6).

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Chart nr 6 Distribution of patients according their hereditary psychiatric disease

Distribution of patients according their psychiatric diseases after concluding their

diseases (Chart7) .

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Chart nr 7 Distribution of patients according their mental illness

Distribution of patients according to family support. 42 of patients are without

family support (Chart nr8).

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Chart nr 8 Distribution of patients according family support

3.2 Clinical oral examination of patients

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

Distribution of positive diagnostic of patients according to their clinical

examination areas follows 49 patients had teeth decay, 37 patients with radicular roots,
parodontal diseases 45 patients and 32 with edentation. (Chart nr 10)
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Chart nr 10 Distribution of diagnostic of patients according the clinical exam

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

Following clinical examination of edentulous patients was observed that 6 cases of

total edentulism, 23 cases have stretched partially edentulous and 15 partially edentulous
cases reduced (Chart nr12 ).

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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).

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Chart nr 15 Distribution of patients according other auxiliary methods of brushing

The distribution of patients according to the technique of brushing. 18 patients and 12

patients using the Bass technique and Fones technique respectively.(Chart nr 16)

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Chart nr 16 Distribution of patients according their technique of brushing

Distribution of patients according the previous dental work: 35 extractions, 19 with

dental fillings and 27 with dental scaler (Chart nr 17).

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Chart nr 17 Distribution of patients according the previous dental work

Following clinical examination of edentulous patients was observed that 13 cases

had prosthodontic work (Chart nr 18).

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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

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.
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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

Chart nr 23 Average index of the patients including in this studies

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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.

Depression Schizophrenia Drug abuse Dementia Anxiety

Depression 0.003 0.08 0.2 0.23

Schizophrenia 0.03 0.01 0.004
Drug abuse 0.13 0.08
Anxiety 0.15
Chart nr 25 P value of the media

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

In our study involving 87 patients at the UMF Cluj hospital department of

psychiatry we obtain a response rate of 59.7%. In another study by Kumar M. et al at 2006,
the rate of response was 81.8%. The distribution of sex in our study was as follows 35% were
men and 65% were women, whereas in Kumar M. et al at 2006 58.3% were males and 41.7%
were females. In another study made in Sweden by Annsofi Johannsen in 2006 about anxiety,
exhaustion and depression in relation periodontal diseases 54% women and 46% men
participated in the study. In our study we observe that in depression more women than men
had depression.

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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.

There was significant increase in the number of patients with cardiovascular

diseases with mental illness compared to other vascular disease in the studies performed. In
Winner et al 2005 he observed more patients with cardiovascular disease had mental illness.

In this study comparing different mental illness 40% of patients had

depression. Kunugi et al 2004 study showed more patients with depression suffering from
oral hygiene problems. In Gold and Chrousos 2002 the highest rate of mental illness was
panic disorder(45%).

Our studies revealed no difference between family support in Romania whilst

in the U.K 80% had family support.

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%.

According to the parodontal problems 46 % of the patients that we examined

had tartrum, whilst in Annsofi Johannsen study the parodontal problems were more gingivitis
48%.The psychiatric patients that was presented in Kumar M study had poor periodontal
status with high treatment needs; only 1.9% had healthy periodontal tissues, while bleeding
on probing, calculus, shallow pockets and deep pockets were found in 10.5%, 40.6%, 35.3%
and 7.8% respectively.

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.

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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.

According the secondary effects of medication of mental illness the most

common is xerostomia 49% ,the same is in Kenkre L et al,2009 studies.

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

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.

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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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