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Case Report
Obsessive compulsive disorder in dental setting
Preetika Chandna, Nikhil Srivastava1, Vivek Kumar Adlakha
Departments of Paedodontics and 1Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut,
Uttar Pradesh, India
ABSTRACT
Globally, 20% of children and adolescents suffer
from a disabling psychologic illness. Among these,
Obsessive Compulsive Disorder (OCD) is listed by
the World Health Organization (WHO) as one of
the 10 most disabling conditions, with prevalence
rates of OCD in children ranging between 1 to
3%. Pediatric dentists are in a unique position to
diagnose psychological problems in children and
adolescents due to their ongoing relationship with
children and their parents that starts at a very early
age. Timely diagnosis of psychological illness can
result in early intervention as well as better patient
management for the dentist too. The purpose of
this case report is to highlight a case of OCD in an
adolescent girl diagnosed in a dental setting.
KEYWORDS: Psychologic disorder, dental obsessive
compulsive disorder
Introduction
Globally, 20% of children and adolescents suffer from a
disabling psychologic illness.[1] Among these, obsessive
compulsive disorder (OCD) is listed by the World Health
Organization as 1 of the 10 most disabling conditions.[2]
The prevalence rates of OCD in children range between
1% and 3%.[3] OCD has a childhood onset in 80% cases
and is the fourth most common childhood psychologic
disorder.[4] Psychologic disorders of childhood and
adolescence such as OCD largely remain undiagnosed
until significant problems occur later in life related to
impaired school or social functioning and early careers.
The financial burden on the family of the affected person
may also be debilitating. The most evidenced predictor
of psychologic disorder in adult life is a psychologic
disorder during childhood and adolescence.[5] The
impact of OCD early in life can extend over a lifetime —
studies show that there is substantial continuity of
psychopathology, from childhood into adulthood.[6]
Pediatric dentists are involved with prevention,
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2014 | Vol 32| Issue 4 |
Address for correspondnece:
Dr. Preetika Chandna,
Subharti Dental College, Swami Vivekanand Subharti
University, Meerut, Uttar Pradesh, India.
E-mail: drpreetikachandna@gmail.com
Access this article online
Quick response code Website:
www.jisppd.com
DOI:
10.4103/0970-4388.140964
diagnosis, and treatment of dental illness in children
from infancy through adolescence. Pediatric dentists are,
therefore, in a unique position to diagnose psychological
problems in children and adolescents due to their on-
going relationship with children and their parents that
start at a very early age. The American Academy of
Pediatric Dentistry recommended age of first dental
examination of a child is 12 months of age or within
6 months of eruption of the first tooth.[7] Timely diagnosis
of psychological illness can result in early intervention
as well as better patient management for the dentist too.
The purpose of this case report is to highlight the case of
behavioral problem in an adolescent girl.
Case Report
11-year-old girl [Figure 1], reported to the OPD of the
Department of Pedodontics and Preventive Dentistry,
with the chief complaint of pain in tooth in number
16 and the carious decay in number 75, 36 and 46.
Dental treatment proceeded in a planned manner.
However, as treatment progressed (after two visits)
we observed that Farhana would get agitated if the
dental chair were not cleaned in front of her eyes.
Reassuring her that the chair was clean did not allay
her anxiety. During the treatment, she would close her
eyes and appear to be counting silently. Sometimes she
wouldn’t open her mouth till she was done counting.
On completion of dental visit, she would make sure the
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Figure 1: An adolescent girl with symptoms of obsessive compulsive
disorder
chair was returned to the proper position (she would
do it herself if we did not comply with her wishes). The
patient’s mother reported that the girl’s father showed
similar behavior, but they had not visited any doctor
for consultation, so the father’s diagnosis of OCD was
not confirmed.
On talking to her mother, we found out that Farhana
had been suffering from some peculiar behavior
problems since the last 1½ years. At home too, Farhana
arranged all her things in a particular sequence every
time she started studying. She would check repeatedly
if the windows of her room were closed before she
left. She also insisted on counting the number of
steps 4 times every time she went up or downstairs.
Farhana’s mother reported that Farhana counted the
steps leading to her classroom in the school as well
and was frequently late for school due to the counting
and arranging rituals at home. Her school marks were
declining due to all her time-consuming counting and
checking behavior. On further questioning, we found
that her behavior met the Diagnostic and Statistical
Manual of Mental Disorders Fourth Edition-Text
Revision (DSM IV-TR)[8] criteria for OCD with her
obsessions, compulsions and impairment of routine life
[Table 1]. The differential diagnosis of OCD includes
schizophrenia, tic disorders, trichotillomania, anorexia
nervosa, generalized anxiety disorder (GAD), and
autism spectrum disorders.[9] The behavior problem
was explained to Farhana’s mother, and Farhana is
currently undergoing psychologic behavior counseling
for the same.
Discussion
As per the DSM IV-TR, OCD is characterized by
obsessions and compulsions.[8] OCD is a type of
anxiety disorder.[8] Children and adolescents with OCD
331 Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2014 | Vol 32| Issue 4 |
Chandna, et al.: Obsessive compulsive disorder in dental setting
Table 1: Summary of diagnostic criteria for
OCD as per DSM IV-TR
OCD is diagnosed by
A. Either obsessions or compulsions
Obsessions as defined by (1), (2), (3) and (4)
(1) Recurrent and persistent thoughts, impulses, or images that
are experienced, at some time during the disturbance, as intrusive
and inappropriate and that cause marked anxiety or distress
(2) The thoughts, impulses, or images are not simply excessive
worries about real-life problems
(3) The person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralize them with some other thought
(4) The person recognizes that the obsessional thoughts,
impulses, or images are a product of his or her own mind (not
imposed from without as in thought insertion)
Compulsions as defined by (1) and (2)
(1) Repetitive behaviors (e.g., hand washing, ordering, checking)
or mental acts (e.g., praying, counting, repeating words silently)
that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
(2) The behaviors or mental acts are aimed at preventing
or reducing distress or preventing some dreaded event or
situation; however, these behaviors or mental acts either are
not connected in a realistic way with what they are designed
to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has
recognized that the obsessions or compulsions are excessive or
unreasonable. Note: This does not apply to children
C. The obsessions or compulsions cause marked distress, are time
consuming (take more than 1 h a day), or significantly interfere
with the person’s normal routine, occupational (or academic)
functioning, or usual social activities or relationships
OCD: Obsessive compulsive disorder, DSM IV-TR: Diagnostic and
Statistical Manual of Mental Disorders Fourth Edition Text Revision
experience recurrent, uncontrollable obsessions, and
compulsions that are time-consuming (taking up more
than 1 h a day).[8] Obsessions are persistent ideas, thoughts,
images, impulses that are intrusive or inappropriate.[8]
These are characterized by being irrational, excessive,
and unrealistic.[8] Common obsessions include thoughts
about contamination, germs, persistent doubts, e.g.,
door locks, gas knobs, concerns of extreme perfection
and order and fears that one may injure someone. These
obsessions lead to significant anxiety and distress.[8]
Farhana’s obsessions included extreme concern and
agitation about cleanliness of the dental chair and
thoughts about symmetry and order of the dental chair
and books at home.
Children and adolescents with OCD go to considerable
lengths to decrease this anxiety through actions
called “compulsions.” Compulsions are repetitive
behaviors or mental acts performed in response to an
obsession.[8] Common compulsions include excessive
hand washing and bathing, checking, counting over
and over, repeating, doing things in a certain order,
arranging to achieve symmetry, and exactness and
hoarding.[8] Farhana’s compulsions include counting
steps, checking cleanliness of the dental chair and
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Chandna, et al.: Obsessive compulsive disorder in dental setting
arranging objects such as dental chair in our clinic
and books at home. Since compulsions are repetitive
behaviors or mental activities, Farhana’s compulsions
in the dental operatory became evident after two visits
when a repetitive pattern began to be observed, and
treatment became hampered due to time taken to
perform compulsions leading to suspicion of abnormal
behavior characterized by OCD.
Obsessive compulsive disorder can begin at any time
from preschool to adulthood.[10] The mean age of onset
is 9-12 years.[10] In our case, the affected child, Farhana,
was 11-year-old. Prevalence of OCD in children and
adolescents ranges from 1% to 4%.[3] OCD shows a
genetic basis[11] and the patient’s father reportedly
experienced similar symptoms. However, lack of
confirmed diagnosis in the father makes the etiologic
genetic basis questionable. One-third to two-thirds of
children and adolescents with OCD continue to fit the
criteria for the disorder 2-14 years later too.[5] A “difficult
to treat” child or adolescent in the dental office may
very well be an ill-child; an informed pediatric dentist
will know the difference. OCD is differentiated from
tic disorders, trichotillomania and anorexia nervosa as
in these disorders, obsessions are limited to a specific
obsession only (e.g., hair pulling in trichotillomania);
while in OCD, obsessions and compulsions range
over multiple thoughts and behaviors.[9] OCD is
distinguishes from GAD as the obsessions in OCD
are much more intrusive and socially unacceptable.[9]
Pediatric schizophrenia is extremely rare unlike OCD
in childhood and adolescence. Autism spectrum
disorders are distinguished from OCD since they are
accompanied by developmental delay.[9]
A few points that may alert a pediatric dentist to early
signs of OCD are as follows:
1. Insistence by the child or adolescent patient on
doing things in a particular way.
2. Anxiousness or agitation seen in the patient if his/
her wishes not followed exactly.
3. Persistently late patient — OCD rituals are time-
consuming and may lead to patient being delayed
for a dental appointment due to performance of
rituals such as counting steps or checking locks.
4. Patient washing hands excessively, repeating,
counting or checking excessively.
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2014 | Vol 32| Issue 4 |
Summary
Pediatric dentists develop a relationship with parents
of children being treated. With a little knowledge of
psychologic illness, many at-risk children may be
identified and brought into psychologic therapy to
prevent lifelong suffering.
References
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4. Sloman GM, Gallant J, Storch EA. A school-based treatment
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How to cite this article: Chandna P, Srivastava N, Adlakha
VK. Obsessive compulsive disorder in dental setting. J Indian
Soc Pedod Prev Dent 2014;32:330-2.
Source of Support: Nil, Conflict of Interest: None declared.
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