Journal of Psychiatric Research 46 (2012) 684e687

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Journal of Psychiatric Research

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Contribution of orodental status to the intensity of orofacial tardive

dyskinesia: An interdisciplinary and video-based assessment
Philippe Girard a, Claude Monette a, b, c, Louise Normandeau c, Tania Pampoulova d, Pierre H. Rompré a,
Pierre de Grandmont a, Pierre J. Blanchet a, c, e, *
a
Faculty of Dental Medicine, University of Montreal, Canada
b
Centre Jeunesse de Montreal-Institut Universitaire, Canada
c
Louis-H. Lafontaine Hospital, Canada
d
Clinique Nouveau Depart, Town of Mount-Royal, Canada
e
University of Montreal Hospital Centre (C.H.U. Montreal), Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: Tardive dyskinesia (TD) is a neurological motor complication eventually arising in one-third
Received 31 October 2011 of patients chronically exposed to antipsychotic drugs. Some orodental peripheral factors have been
Received in revised form reported to influence TD.
27 January 2012
Objective: To measure orodental factors such as temporomandibular joint function, static occlusal
Accepted 3 February 2012
contacts, and denture condition, and attempt correlations with orofacial TD intensity.
Methods: In this exploratory cross-sectional pilot study, 31 subjects between 30 and 75 years of age were
Keywords:
divided in two groups displaying minimal to mild, or moderate to severe orofacial TD, respectively, and
Tardive dyskinesia
Antipsychotic drugs
underwent a detailed oral, dental, and prosthetic evaluation to capture various aspects of oral health
Schizophrenia compared between the two groups. Blinded video-based TD ratings along a validated scale were obtained
Edentulism to compare dentulous and edentulous subjects, and contrast TD intensity in complete denture wearers
Dental occlusion with and without their own prostheses.
Dental prosthesis Results: None of the factors examined tightly correlated with orofacial TD intensity. However, edentulism
was associated with a higher median orofacial TD rating compared to the dentulous group (p ¼ 0.001).
Further, a significant intra-subject difference was observed in the edentulous subjects rated with their
own complete dentures in place or not (p ¼ 0.028), the dentures attenuating the mean orofacial ratings
by 21.8  7.3%.
Conclusion: Of all orodental factors considered, only edentulism and complete denture wearing influ-
enced oral TD expression, calling for the close monitoring of the dental status in antipsychotic drug-
exposed patients to prevent tooth loss. Further studies to measure the impact of an adequate prostho-
dontic rehabilitation in edentulous subjects with orofacial TD seem warranted.
Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction
Tardive dyskinesia (TD) is an unsolved and potentially disabling
complication encompassing all persistent and often irreversible
abnormal involuntary movements occurring in the setting of
chronic antipsychotic drug (APD) or metoclopramide therapy
(Blanchet, 2003). The resulting movement disorder is often
stereotyped in nature and typically involves the orobuccolingual
musculature to include twisting and protruding movements of the
* Corresponding author. Faculty of Dental Medicine, University of Montreal, P.O.
Box 6128, Succ. Centre-ville, Montreal (QC), Canada H3C 3J7.
E-mail address: Pierre.J.Blanchet@umontreal.ca (P.J. Blanchet).
tongue, lip smacking and puckering, facial grimacing, and chewing
movements. Movements may be confined to the oral area to
produce the classical “bucco-linguo-masticatory syndrome”, or
spread to the axial and limb musculature. Oral dyskinesia may be
an under-recognized source of pain (from myalgia, temporoman-
dibular joint dysfunction, traumatic lesions), tooth wear, and
impaired retention of dental prosthetic devices (Blanchet et al.,
2005). Chewing difficulty, related to the dyskinetic movements or
inability to wear dentures, and dysphagia, may occur. Speech is
impaired in a fraction of cases, adding to the social embarrassment
patients experience due to cosmetic reasons or loudness of the
dyskinetic movements. A recent report reminded the medical
community that one-third of patients chronically exposed to
conventional and/or atypical APDs still manifest TD, although some

0022-3956/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpsychires.2012.02.003
 P. Girard et al. / Journal of Psychiatric Research 46 (2012) 684e687
atypical second-generation APDs afford a one-third reduction in
cumulative TD risk relative to conventional first-generation APDs
when assessed prospectively over 4 years (Woods et al., 2010). The
risk is generally reported as greater in older adults, with prevalence
rates that may exceed 50%. As TD remains an elusive drug
complication, it is not surprising that the treatment options avail-
able are non specific and produce mixed results.
TD is a neurological complication associated with abnormal
inhibitory pallidothalamic outflow (Damier et al., 2007), but
peripheral factors may still contribute. Although its intensity has
been reported to be greater in edentulous subjects (Myers et al.,
1993), this aspect of TD research has been neglected and the
most influential orodental factors on TD severity remain under
investigated. Limited observations have been published to deter-
mine the place of dental prosthetic approaches in TD relief (Sutcher
et al., 1971; Lauciello and Appelbaum, 1977; Tublin, 1989; Kai et al.,
1994; Katz et al., 2010), with the idea to provide better static
occlusal contacts and adequate proprioceptive signals from the
periphery. The net impact of such interventions has not been
quantified. This exploratory cross-sectional pilot study aimed to
identify the relation between orodental factors and the intensity of
TD expression in patients under long-term APD treatment, under
the hypothesis that some of these, edentulism and reduced vertical
occlusion in particular, contribute to worsen TD intensity.
2. Methods
2.1. Patient population
Participants were recruited from the outpatient clinics of
a single psychiatric teaching hospital affiliated with the University
of Montreal. In order to minimize selection biases, a convenience
sample of patients under long-term APD treatment for chronic
schizophrenia or schizoaffective disorder, meeting DSM-IV diag-
nostic criteria and regularly followed by a psychiatrist, were
recruited by a nurse according to three basic criteria: 1) age
between 30 and 75 years; 2) stable APD therapy for at least 3
months; 3) notation of the presence of TD movements in the
patient’s chart. The investigators were unaware of the severity of
the TD manifestations prior to their visit to the outpatient clinic. All
these patients were examined under their regular drug regimen.
The study was approved by the Research Ethics Board, and all
participants (and/or their legal guardian whenever applicable)
provided informed written consent long before the visit.
2.2. Procedure
Participants were first asked to fill a survey on their oral health
quality of life (pain and masticatory difficulties), and dental pros-
theses if applicable (level of satisfaction, comfort, frequency of
wearing). A detailed oral, dental, and prosthetic examination was
then conducted. The integrity of the static occlusal contacts,
measure of the vertical occlusion dimension (in mm), number of
teeth contacts, tooth wear, lip mucosa, degree of resorption of the
edentulous alveolar ridge, occlusal plane, as well as prosthetic
stability and retention, were examined. The objective measures of
temporomandibular joint (TMJ) dysfunction, including mandibular
mobility, joint components and muscles, spontaneous and evoked
pain, were also assessed with the Helkimo index (Helkimo, 1974),
which splits patients in 5 groups without symptoms or with mild to
severe symptoms.
A videotape of the orofacial TD movements was obtained, with
and without dentures in place whenever applicable, and 3 stan-
dardized clips lasting 3e3.5 min were generated while the subject
was at rest, talking, and performing drawings on a tablet. These
685
clips were subsequently proposed in random order to a neurologist
(TP) with experience in TD assessment, unaware of the study
protocol, who rated all clips in random order. The orofacial move-
ments were scored along the relevant items on the Tardive Dyski-
nesia Rating Scale (TDRS). This video assessment allowed the
examination of the edentulous group ratings relative to the
dentulous group, and sub analysis of the edentulous subjects
customarily wearing complete sets of upper and lower dentures
(C/C), to determine the impact of dental prosthetic use on TD
expression.
2.3. Statistics
The participants were divided in two groups according to the
intensity of orofacial TD movements based on the Abnormal
Involuntary Movements Scale (AIMS) item #8 for global judgment
scored during the actual visit: group 1 (rating of 1e2 points, rep-
resenting minimal to mild signs) vs. group 2 (rating of 3e4 points,
representing moderate to severe signs). The results of isolated oral
factors are provided in percentage for each group. Ages and dura-
tion of drug exposure were compared with two-sample t-tests.
ManneWhitney test and Fisher’s exact test were used when
appropriate to measure the association between orodental
parameters and TD intensity. The participants were also divided on
the basis of their dentulous or edentulous state. Median orofacial
TDRS scores in those two groups were compared with the
ManneWhitney test. Intra-subject difference in TDRS ratings, with
and without habitual dental prostheses, was assessed with the
Wilcoxon test.
3. Results
Thirty-six subjects (15F:21M) between 34 and 74 years of age
(mean  SE: 59.2  1.4) were examined. The mean (SE) APD
exposure for the entire cohort extended to 30.3 (2.1) years. In 5
subjects, the TD manifestations documented in the chart were no
longer present at the time of examination, leading to rejection as
a result. The remaining 31 participants were split in group 1
(9F:12M or 68%) and group 2 (5F:5M or 32%). The age distribution
between the two groups was similar, with respective means (range)
of 59.5  2.1 years (34e74) and 59.8  1.9 years (48e68). The
duration of antipsychotic drug treatment was slightly longer in
group 1 while the distribution of current conventional and/or
atypical APD treatment did not differ between the two groups (see
Table 1). Personal but unverified accounts from edentulous subjects
yielded a mean duration of edentulism of 18.89  2.58 years (range
2e40). The answers to the survey provided by each group (dentu-
lous and edentulous) yielded no difference in terms of prevalence
of orofacial pain (p ¼ 0.63), masticatory difficulties (p ¼ 0.77), and
frequency of use and stability of removable complete or partial
dentures. In accordance with the over-representation of minimal to
mild orofacial TD cases in our cohort, 21 subjects (68%) reported
being not self-conscious or distressed by the presence of TD when
queried along the AIMS item #10. Only 5 subjects (16%) reported
mild to moderate discomfort from TD, and the latter were younger
than the other participants examined (p ¼ 0.038, t-test).
A lack of correlation was found between the orodental param-
eters examined and orofacial TD intensity in our cohort (Table 1).
Concerning the dental status, the 12 dentulous subjects had
between 4 and 28 residual teeth (0-15 maxillary, 4-14 mandibular),
but the number of missing teeth did not differ between the two TD
groups (p ¼ 0.30), both for the maxilla (p ¼ 0.29) and mandible
(p ¼ 0.36). Nineteen (61.3%) subjects were edentulous, 12/21 in
group 1 and 7/10 in group 2. Of those, only 8 subjects were
customarily wearing complete upper and lower dentures (C/C). The
686 P. Girard et al. / Journal of Psychiatric Research 46 (2012) 684e687

Table 1
Orodental status in the two groups of patients with orofacial tardive dyskinesia (TD)
of minimal to mild (group 1; n ¼ 21) vs. moderate to severe (group 2; n ¼ 10)
intensity. Data are provided in percentages relative to each group (except for
duration of drug exposure).

Group 1 Group 2 P
M:F ratio 57.1:42.9 50.0:50.0 1.00
Duration of antipsychotic drug 34.0  2.3 24.4  4.7 0.048a
exposure (years)
Distribution of current antipsychotic 0.67
drug treatment
- First-generation 9.5 20.0
- Second-generation 52.4 40.0
- Both 38.1 40.0
Edentulism 57.1 70.0 0.70
Complete denture wearers (C/C) 28.6 20 1.00
Normal edentulous alveolar ridge 42.9 10.0 0.11
Normal occlusal plane (n ¼ 19j6) 73.7 16.7 0.023
Adequate vertical occlusion 50.0 14.3 0.18
dimension (n ¼ 20j7) Fig. 1. Box-plot combined with a symmetrical dot density providing individual oro-
Normal lip mucosa 100 70.0 0.027 facial TDRS ratings generated from blinded video-based assessment, and median
Adequate prosthetic stability 40 50 1.00 values comparing edentulous patients (without their dentures if applicable) to
and retention (n ¼ 10j4) dentulous patients (p ¼ 0.001; ManneWhitney test).
Helkimo dysfunction index 0.54b
Asymptomatic 19.0 20.0
Slightly symptomatic 57.1 70.0 were generally unsupportive of our basic hypothesis. They agree
Moderately symptomatic 23.8 10.0 with those of a large cohort of female in-patients over 50 years of
a
Two-sample t-test. age exposed to phenothiazines with a documented prevalence of
b
ManneWhitney test. Otherwise, Fisher’s exact test was used. orofacial TD of 35% regardless of dental state (Brandon et al., 1971).
Our results confirm that TD has no significant impact on self-
distribution of C/C subjects was balanced between group 1 (N ¼ 6/ assessed oral pain perception in schizophrenia (Blanchet et al.,
21 or 28.6%) and group 2 (N ¼ 2/10 or 20.0%). The other edentulous 2008), or on some other aspects of subjective oral health quality
subjects wore no dentures (N ¼ 5) or only the upper one (N ¼ 6). of life, such as mastication and denture wearing habits during the
Excluding those wearing no dentures, the proportion of subjects day. Moreover, no correlation was apparent between the vertical
with normal occlusal plane was higher in group 1 (73.7% 14/19) occlusion dimension, number of missing teeth, or TMJ function, and
than in group 2 (16.7% 1/6, p ¼ 0.023). Further, the vertical occlu- orofacial TD intensity in the cohort examined. Edentulism alone
sion dimension was deemed adequate in 50% (10/20) of subjects in was found in a similar proportion between TD group 1 (57.1%) and
group 1 and 14% (1/7) in group 2 (p ¼ 0.18), and the condition of the group 2 (70.0%) participants. It is conceivable that the low rate of
edentulous alveolar ridge showed slightly more mandibular bone normal occlusal plane in group 2 is in part a consequence of the
resorption in group 2 (p ¼ 0.11). All our subjects were found to dyskinetic movements producing excessive natural or prosthetic
display asymptomatic up to moderate TMJ dysfunctions on the tooth wear.
Helkimo index. Further analysis revealed that certain TMJ prob- These findings suggest that in the hierarchy of events contrib-
lems (noise, locking, deviation) tended to be more common in uting to TD intensity, peripheral orodental factors play a minor
group 2 (60% group 2 vs. 24% group 1, p ¼ 0.11). While no subject in role. Admittedly, a larger number of subjects with higher TD
group 1 presented an abnormal lip mucosa, 30% (3/10) of subjects scores would have been necessary to strengthen this conclusion.
in group 2 did (p ¼ 0.027). In the 14 denture wearers, the pros- Although some authors have expressed the opinion, based on
theses were generally worn-out and felt to be stable and retentive clinical practice, that changes in vertical occlusion have an impact
in 6 subjects (4 in group 1, 2 in group 2). In the subgroup of C/C
subjects, prosthetic stability and retention were generally inade-
quate, to a mild degree in 3 participants (37.5%), and to a moderate
to severe degree in 5 others (62.5%). Inadequacy in occlusal vertical
dimension with dentures in place was variable but almost constant
(7 out of 8 subjects), by 0e2 mm (mildly faulty) in 4 (50%) to >
2 mm (moderately to severely faulty) in 3.
Relevant TDRS items blindly scored on video clips revealed
a difference in median orofacial TD intensity between the dentu-
lous and edentulous participants (Fig. 1), with higher scores in the
latter group (p ¼ 0.001). Moreover, an intra-subject difference was
found for the C/C group (Fig. 2), with higher orofacial TD scores
obtained without dentures in place compared to denture wearing
(p ¼ 0.028). The mean reduction in orofacial TD ratings afforded
by denture wearing in this subgroup was 21.8  7.3%.

4. Discussion

Although the severity of orofacial TD scores has correlated with

age more clearly than with non-orofacial TD (Glazer et al., 1988), Fig. 2. Intra-subject difference in individual orofacial ratings of habitual complete
the oral status specifically appeared to have little bearing on oro- denture wearers (C/C subgroup), with and without dentures in place (p ¼ 0.028;
facial TD intensity in our small sample biased for age, and findings Wilcoxon test).
 P. Girard et al. / Journal of Psychiatric Research 46 (2012) 684e687
on TD (Tublin, 1989; Sutcher et al., 1998), we were unable to link
this factor with TD intensity. We are confident that our detailed
clinical examination allowed the adequate measure of this
parameter. Further, the subjects with the greater vertical occlusion
anomalies, namely the edentulous subjects, were well balanced
between the two TD groups.
Given the impact of edentulism and dental prostheses on oral
health and function (Myers et al., 1993; Sutcher et al., 1998), these
factors were examined more closely. Edentulism was common in
our sample (61.3%). In one study, the proportion of edentulism
(39%) in a schizophrenic outpatient subgroup between 55 and 64
years of age was double relative to the general population
(McCreadie et al., 2004). Tooth loss in schizophrenia is multifac-
torial and largely attributable to a high prevalence of caries and
periodontal disease, conditions correlated with the severity of the
mental illness and exacerbated by xerostomia, high soft drink
intake, and smoking habits (Arnaiz et al., 2011; C. Monette,
unpublished observations). Nonetheless, only one quarter (25.8%)
of our edentulous subjects was wearing dentures. The oral TD
intensity in our sample unlikely explains why dentures were not
fitting and worn, but this situation can indeed arise (Brandon et al.,
1971). In older edentulous TD patients unable to wear dentures,
consulting first a prosthodontist will help decipher whether this is
primarily attributable to the presence of oral dyskinesia, requiring
specific management strategies including reassessment of the
offending APD drug treatment and use of antidyskinetic agents
such as tetrabenazine and botulinum toxin, or marked alveolar
bone resorption. Interestingly, the blinded video-based TD ratings
were found higher in edentulous than dentulous subjects. In
contrast, wearing the habitual set of dentures in completely
edentulous subjects was associated with lower mean orofacial TD
ratings by nearly 22%, arguing for the removal of dentures prior to
clinical assessment for the adequate documentation of oral TD
intensity. This result is somewhat surprising in view of the imper-
fect fitting documented, but in line with other clinical observations
(Lauciello and Appelbaum, 1977; Tublin, 1989; Kai et al., 1994; Katz
et al., 2010; Sutcher et al., 1998). It should not be interpreted as
reflecting the presence of edentulous orodyskinesia, a separate
entity in chronically edentulous subjects often without dentures
(Koller, 1983; Blanchet et al., 2008). Unlike TD, the latter condition
is limited to the oral area and produces no involuntary tongue
protrusions, spares the tongue at rest when the mouth is open, and
may completely respond to a prosthetic approach. It was impos-
sible to ascertain which of the edentulous state and TD condition
appeared first in our sample, but the presence of non-orofacial TD
movements in half of the subjects, presence of tongue movements
at rest, and incomplete relief in those wearing dentures, suggested
TD rather than edentulous orodyskinesia as etiology for the oral
movements observed. The lack of correlation between the vertical
occlusion dimension and orofacial TD intensity in our small group
of denture wearers may suggest that the vertical dimension value
per se is not a critical consideration in order to alleviate non-
dystonic, abnormal oral movements using a dental prosthetic
approach. Providing proprioceptive inputs as well as structural
support to the orofacial musculature may be key features in reha-
bilitation in these patients.
In conclusion, although APD-induced central nervous system
signaling events are most important in TD induction, its expression
is influenced by edentulism and complete denture wearing. This
argues in favor of a close monitoring of the dental status in APD-
exposed patients to prevent edentulism. Our limited cohort cannot
answer the question whether the quality of the prosthodontic
rehabilitation offered produces a distinct impact on TD intensity in
edentulous subjects. Further studies measuring the impact of proper
dentures in edentulous TD subjects are worth pursuing.
687
Role of funding source
This work was supported in part by a grant from the National
Alliance for Research on Schizophrenia and Depression (USA) e
NARSAD-The Brain and Behavior Research Fund, without further
role in study design or data collection and analysis.
Contributors
The authors Girard, Monette, de Grandmont, and Blanchet
designed the study. The authors Girard, Monette, and Blanchet
were involved in data collection. The author Normandeau recruited
the study participants and author Pampoulova blindly reviewed all
video clips for motor assessment. The authors Girard, Rompré, and
Blanchet were involved in data analysis. The author Blanchet wrote
the first draft of the manuscript and submitted it with the approval
of all co-authors.
Conflicts of interest
All the authors declare that they have no conflicts of interest.
Acknowledgments
The Authors wish to thank all the participants in the study, and
the staff of the dental and psychiatric outpatient clinics of the
Louis-H.-Lafontaine Hospital, where the study was conducted.
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