being angry or demanding), as they comprise a large segment of

the esthetic dentistry patient population.

Adjustment disorders are diagnosed when individuals lack
adequate coping skills to handle specific life events, such as relationship
breakups, poor grades, job loss, illness, and aging. This
diagnosis is rendered when there is a specific event that causes
marked distress that interferes with social and/or occupational
functioning, in excess of what would normally be expected. It
has been criticized as being too vague a diagnostic category, yet
clinicians do find it to be useful and the dentist is likely to
encounter it. Some patients will be reacting within normal limits
to stressful life events, and others will react pathologically. Both
subcategories will potentially require extra management care to
optimize dental treatment success.
Mood disorders
Depression
These two patients exemplify some of the major challenges
facing
the dentist when dealing with patients with depression, a
highly prevalent mood disorder. In the case of Steve, the challenge
is primarily clinical management of his present mental and dental
status coupled with enhanced oral disease prevention. For Susan,
the challenges include detecting the possibility of undiagnosed
depression, successful referral for mental health treatment, and
staging of esthetic dental rehabilitation to minimize treatment
failure and maximize the positive effects of improved dental
esthetics on her overall health and well‐being.
Elements of successful dental treatment of behaviorally challenging
patients include careful screening and assessment, psychiatric
consultation or referral, and clear communication,
particularly in the area of treatment planning. The extra time
and effort can be more than offset by enhanced patient comfort
and compliance, and thus greater treatment success and dentist
satisfaction. It is also very effective to foster close communication
among all members of the dental team—from receptionist
to hygienist to assistant to dentist—since patients often reveal
important information to staff members, who can alert and
guide the dentist to a possible management problem early
enough in the process that critical adjustments can be made and
conflicts or errors prevented.
Box 2.1 lists the diagnostic criteria for major depression in the
current Diagnostic and Statistical Manual used in psychiatry and
psychology (DSM‐5).2 It is helpful for dentists and their treatment
teams to be familiar with these criteria when evaluating
new and returning patients for esthetic treatment. It is also adviable
that medical history forms used in esthetic dental practice
include specific questions that can gently yet clearly elicit signs
that a patient may be suffering with depression, whether previously
diagnosed or not.4,5 Alternatively, you may prefer to administer
a brief, validated depression questionnaire such as the Beck
Depression Inventory (BDI).6 Although Steve was forthcoming
about his depression history, many patients unfortunately feel
too stigmatized to offer such details voluntarily. Specific questions
and validated questionnaires are no guarantee, but they do
increase the probability of disclosure significantly. Box 2.2 lists
suggested depression‐related questions for inclusion on medical
history forms.
Our patient Steve illustrates some of the most important management
considerations when dealing with a history of depression.
First and foremost, you and your staff should approach a
patient like Steve in a manner that is respectful, concerned, and
competent. He should be made to feel comfortable with having
disclosed details of his illness, since only with such disclosure
can he be treated safely and effectively. He should be reassured
that his dental needs can be addressed, after some preliminary
data gathering, and that his psychiatric history will be kept
confidential. It will be necessary for the dentist to obtain the
patient’s written consent to communicate with the psychiatric
treatment team, in this case consisting of his psychiatrist and
psychotherapist. This consent must be given by the patient to all
of the doctors who wish to communicate with each other, and is
a standard aspect of psychotherapy practice.
Once consent for release of information has been obtained,
the dentist should speak to the patient’s prescribing psychiatrist