her oral examination.

However, her behavior and medical

history
suggested that she might be suffering from an as yet
undiagnosed major depressive episode. The best way for you to
approach a patient like Susan would be to establish rapport with
her as well as possible in the initial visit by carefully reviewing
her medical and dental histories and gently inquiring as to
whether she had considered that she might be suffering with
depression. You should be prepared to give her contact information
for several well‐regarded psychiatrists and psychotherapists
in the community. The best‐case scenario is that you have
accurately detected a case of depression and that the patient will
follow up with psychiatric treatment.
Whether or not this occurs, the dental treatment plan should
begin with scrupulously clear communication between you and
the patient. You should use photos of esthetic smiles to elicit a
sense of what she expects as an esthetic result, and ascertain
whether or not her expectations are reasonable. If they are not,
some extra time spent illustrating what she can expect will help
to prevent disappointment and difficulties at the end of the
active treatment phase. Once you and the patient have worked
out an agreement on the esthetic goals, you should prepare a
detailed treatment plan—including such details as a description
of what she will experience with her temporary restorations,
how long appointments should take, the projected
interval of time between appointments, and the realistic appearance
of the final restorations.4,5 The patient should then be
asked to sign a statement indicating that she has understood
and agrees to the treatment plan. In this way, important details
are discussed in advance, consent to the treatment plan is as
fully informed as possible, and treatment can proceed in an
atmosphere of enhanced trust.
Successful behavioral management might require the patient’s
visits to be shortened to accommodate her emotional state. She
may also require extra encouragement and reassurance. Clinical
dental management should include intensive oral hygiene
instruction and frequent oral prophylaxis with topical fluoride
application, particularly if the patient commences pharmacotherapy
with antidepressant medication, putting her at risk of
xerostomia and caries. As Susan’s depression ameliorates, and as
Steve continues to enjoy emotional stability through psychiatric
care, the improvement in their smiles is likely to contribute
significantly to their emotional health. It is well documented
that renewed dental health, especially when dental esthetics have
been improved, can contribute to a depressed patient’s recovery
and long‐term emotional stability through enhanced self‐esteem
and confidence (Figure 2.2).4,5,7,8
Bipolar disorder
This is an unlikely scenario, but if it were to occur, your best
course of action would be to urge the patient to seek emergency
psychiatric care for bipolar disorder (BD). Individuals experiencing
a manic episode, as illustrated above, often experience a very
rapid mood swing back to deep depression, and self‐destructive—
even suicidal—behaviors are not uncommon. The scenario is
unlikely, since a manic, euphoric patient is probably not going to
be thinking about visiting his dentist! The diagnostic criteria for
BD are extremely complex, and therefore beyond the scope of this
chapter. The interested reader is advised to consult the DSM‐5.2
You are much more likely to encounter a patient with BD who
has been previously diagnosed and whose mood has been stabilized
by psychiatric treatment. As with depression, you should
obtain the patient’s written consent to consult with the psychiatric
treatment team, to review the patient’s current mental
status,
medications, and any risk of adverse interactions with
local anesthetics and other medications commonly used in
dental
treatment, as well as possible considerations for dental
treatment timing and staging.
Patient management should be guided by the awareness
that, despite psychiatric treatment, the patient with BD may still