to treatment, and ability to tolerate extensive dental

procedures.9,10 As with unipolar depression, it is advisable for

you to do your utmost to make sure the patient’s expectations of
the final result are realistic, to provide a detailed treatment plan,
and to have the patient sign an agreement based on the aforementioned
criteria. This patient will likely require a little extra
patience and encouragement, and possibly shorter appointments.
The patient with established BD is likely to be taking an
antidepressant as well as a mood stabilizer, such as lithium or
lamotrigine, all of which may cause chronic xerostomia. A dry
mouth management protocol may be required.
Whereas the patient with BD going through a depressive
phase will often present with poor oral hygiene, those having just
experienced a manic phase of the disorder may show evidence of
overly vigorous flossing and brushing, such as notched gingival
lesions and excessive cervical tooth abrasion.9 Once again, thorough
and frequent oral prophylaxis and oral hygiene instruction
are of paramount importance, along with use of topical fluorides
and dietary counseling.
As with the depressed patient, a relatively small investment in
time, effort, and information gathering promotes successful relationships
and treatment of the esthetic dental patient with BD.
The opportunity to enhance the self‐esteem and psychological
well‐being of such patients can be particularly satisfying for the
esthetic dental team.
Obsessive‐compulsive disorder
At this point, the dentist decided to contact a psychologist to
whom he often referred, who confirmed that Jerry was most
likely suffering with a type of anxiety disorder known as obsessive‐
compulsive disorder (OCD), the diagnostic criteria of which
are found in Table 2.2. The dentist’s role, in this instance, was to
Case example: Obsessive-compulsive disorder
Jerry had been a highly particular patient from his very first
visit, but his behavior really raised alarms when he failed
to show up for his recall appointment, especially when he
disclosed the reason for his “no‐show.” He had chosen to be
treated in this practice based on its reputation not only for
high‐quality esthetic dentistry, but even more for its adherence
to strict sterilization guidelines. Office sterility was,
according to Jerry, always his greatest concern. After his
previous dentist retired it had taken him a while to find
another office he could trust to be as clean as he needed it
to be. Jerry was willing to drive from his home over an hour
away from the practice.
Another concern of Jerry’s was radiation exposure. He
refused most dental radiographs, except when a tooth was
symptomatic or to check an endodontic procedure, and
insisted on being fully swathed in lead aprons. Jerry also
elected to have his procedures done without local anesthetic.
He explained that the discomfort was less aversive
than his concern about possible needle contamination. The
dental team members were willing to comply with these
limitations and were careful to document in the patient’s
chart whenever he declined a recommendation.
Jerry was otherwise a patient who was easy to accommodate:
he paid his bills on time, complied with treatment,
and reliably arrived early for his appointments, always
providing adequate notice when he needed to change his
appointment schedule.
When he failed to arrive for his recall, the dentist and his
staff were concerned, since it was so extraordinary, and their
concerns were only heightened when they learned his reason:
“You see, after I drove to the appointment and parked my car,
I remembered that the hygienist had just returned from her
maternity leave. I became afraid that if someone didn’t pick
up after their dog and I unknowingly stepped in it, I could
pass the germs on to the hygienist, who might then pass
them on to her new baby and make her sick. I just couldn’t
come in. So I drove all the way back home. I’m so sorry!”
Table 2.2 Diagnostic Criteria for Obsessive Compulsive Disorder (OCD)
Must exhibit
obsessions or
compulsions
The obsessions and/or compulsions cause
marked distress, are time‐consuming (take
more than 1 h per day), or interfere
substantially with the person’s normal routine,
occupational or academic functioning, or usual
social activities or relationships.
The content of the obsessions or compulsions
should not be restricted to any other major Axis
I psychiatric disorder, such as an obsession with
food in the context of an eating disorder.
Obsessions Recurrent and persistent thoughts, impulses,
or images experienced, at some time during
the disturbance, as intrusive and inappropriate
and cause marked anxiety or distress.
These thoughts, impulses, or images are not
simply excessive worries about real life
problems.
There is some effort by the affected person to
ignore or suppress such thoughts, impulses, or
images, or to neutralize them with some other
thought or action.
At some time, the affected person recognizes
that the obsessions are a product of his or her
own mind rather than inserted into his or her
own mind from some outside source.
Compulsions Repetitive activities (e.g., hand washing,
ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently).
The person feels driven to perform these in
response to an obsession or according to rules
that must be applied rigidly.
These behaviors or mental acts are performed
in order to prevent or reduce distress, or
prevent some dreaded event or situation.
However, they are either clearly excessive or
not connected in a realistic way with what
they are designed to neutralize or prevent.