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Dental prosthetic rehabilitation approach in tardive dyskinesia with edentulism: A case report
Schizophrenia Research 136 (2012) 162–163
Contents lists available at ScienceDirect
Schizophrenia Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s
Letter to the Editor Dental prosthetic rehabilitation approach in tardive dyskinesia with edentulism: A case report
Dear Editors, Tardive dyskinesia (TD) remains a prevalent and potentially disabling motor complication during chronic treatment with dopamine receptor-blocking agents (Woods et al., 2010), typically involving the bucco-linguo-masticatory musculature. As induction mechanisms remain elusive, pharmacological treatment produces mixed results. Although TD is associated with abnormal pallidothalamic outflow (Damier et al., 2007), intensity has been retrospectively reported greater with edentulism (Myers et al., 1993). Limited observations suggest that dental prosthetic rehabilitation affords relief against TD (Sutcher et al., 1998; Katz et al., 2010), along the idea to improve proprioception from the oral cavity. The objective impact of this intervention has not been quantified. We used this approach in a 66 year-old male patient with a long history of schizoaffective disorder, who provided written consent for the treatment and video recording and use. He was an active smoker with a past history of alcoholism and edentulism, and was chronically treated with monthly haloperidol i.m. injections until 3.5 years before his visit. He met the DSM-IV clinical criteria for TD but the timing of onset remained undetermined. His drug regimen included risperidone 2 mg bid, lithium carbonate 900 mg daily, procyclidine 10 mg bid, and diphenhydramine 25 mg HS. Procyclidine was weaned, but TD continued unabated. A computed tomography scan of the brain revealed a small lacune in the right lenticular nucleus with normalsized ventricles. He was wearing a worn-out upper denture only because the mandibular piece had become unstable. He was dissatisfied with his upper denture because of instability and difficulty to speak and chew properly. Jaw pain was reported. On examination, oral hygiene was deficient and a maxillary prosthetic stomatitis was documented, in addition to areas of keratosis along the mandibular alveolar ridge. Advanced mandibular bone resorption was present. His tongue was large with thrusting movements observed at rest. With his original upper denture in place or not, fairly marked stereotyped lingual and jaw dyskinesia was apparent, along with mild purposeless finger movements. Since there is no standard dental prosthetic approach to treat TD, two new sets of dentures were fabricated and adjusted. Prosthetic parameters (occlusal vertical dimension (OVD), centric relation, occlusal plane, phonetics, esthetics) were determined by two clinicians to prepare the first complete dentures. Once the patient felt comfortable, he wore them for 2 months before a self-assessment form and oral examination were completed (T1). Subsequently, he kept the new maxillary denture but another mandibular denture was prepared to arbitrarily raise the OVD by 2 mm between two points when the occluding members are in contact, to be reassessed 2 months later (T2). Videoclips of the orofacial TD movements were generated, with and without dentures in place, while the subject was 0920-9964/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2011.07.004
at rest and drawing circles on a tablet, at baseline (T0) and with each set of dentures (T1, T2). These clips were proposed to an investigator unaware of the condition of the patient, who rated them in random order along relevant orofacial items of the Tardive Dyskinesia Rating Scale [TDRS] (Simpson et al., 1979). During the rehabilitation process, jaw pain resolved and the patient reported better comfort and satisfaction, equivalent with the two new sets of dentures. The orofacial TD intensity without dentures in place was stable throughout the observation period of 6 months, with a coefficient of variation of 12.4% in video-based ratings. With the original upper denture in place at baseline (T0), orofacial TDRS scores were unchanged. However, orofacial TDRS scores were reduced by 44% (T1) and 50% (T2) relative to baseline with the new complete dentures in place (Fig. 1 and Video 1). This case of moderate orofacial TD illustrates how poorly compensated edentulism may contribute to TD intensity, and the distinct impact of dental prosthetic rehabilitation measured on a validated scale. Denture instability does not always result from uncontrollable oral TD movements and should not be necessarily viewed as an obstacle to deter such approach. We do not feel this case represents edentulous orodyskinesia, since the oral manifestations persisted at rest with the mouth kept open, were associated with involuntary extraoral movements, and did not entirely disappear upon insertion of adequate dentures (Koller, 1983; Blanchet et al., 2008). The specific OVD value reached did not seem to be a critical factor to achieve benefit. Providing proprioceptive inputs and supporting orofacial structures may be more important considerations (Sutcher et al., 1998). This interesting result confirms other clinical observations and calls for further studies measuring the
Fig. 1. Blinded, video-based, orofacial tardive dyskinesia ratings, without and with the original upper denture in place at baseline (T0), and with the two sets of dentures proposed during the rehabilitation process (T1 and T2).
Letter to the Editor
impact of proper dentures in edentulous TD subjects who are candidates for rehabilitation. Supplementary materials related to this article can be found online at doi:10.1016/j.schres.2011.07.004. Role of funding source None. Contributors PB was involved in the conception, organization, and execution of the study, and writing of the manuscript. PG was involved in the conception and execution of the study, under the supervision of GG and PdeG. TP was responsible for the video-based motor ratings, and PR analyzed them. All co-authors reviewed the manuscript. Conflict of interest All authors declare that they have no conflicts of interest that could influence this work. Acknowledgements None.
References Blanchet, P.J., Popovici, R., Guitard, F., Rompre, P.H., Lamarche, C., Lavigne, G.J., 2008. Pain and denture condition in edentulous orodyskinesia: comparisons with tardive dyskinesia and control subjects. Mov. Disord. 23, 1837–1842. Damier, P., Thobois, S., Witjas, T., Cuny, E., Derost, P., Raoul, S., Mertens, P., Peragut, J.C., Lemaire, J.J., Burbaud, P., Nguyen, J.M., Llorca, P.M., Rascol, O., French Stimulation for Tardive Dyskinesia (STARDYS) Study Group, 2007. Bilateral deep brain stimulation of the globus pallidus to treat tardive dyskinesia. Arch. Gen. Psychiatry 64, 170–176. Katz, W., Kaner, T., Carrion, J., Goldstein, G.R., 2010. The management of a completely edentulous patient with tardive dyskinesia. Int. J. Prosthodont. 23, 217–220. Koller, W.C., 1983. Edentulousness and oral dyskinesia. Am. J. Psychiatry 140, 510. Myers, D.E., Schooler, N.R., Zullo, T.G., Levin, H., 1993. A retrospective study of the effects of edentulism on the severity rating of tardive dyskinesia. J. Prosthet. Dent. 69, 578–581. Simpson, G.M., Lee, J.H., Zoubok, B., Gardos, G., 1979. A rating scale for tardive dyskinesia. Psychopharmacology (Berl) 64, 171–179. Sutcher, H., Soderstrom, J., Perry, R., Das, A., 1998. Tardive dyskinesia: dental prosthetic therapy. Panminerva Med. 40, 154–156. Woods, S.W., Morgenstern, H., Saksa, J.R., Walsh, B.C., Sullivan, M.C., Money, R., Hawkins, K.A., Gueorguieva, R.V., Glazer, W.M., 2010. Incidence of tardive
163
dyskinesia with atypical versus conventional antipsychotic medications: a prospective cohort study. J. Clin. Psychiatry 71, 463–474.
Pierre J. Blanchet Faculty of Dental Medicine, University of Montreal, Montreal (QC), Canada University of Montreal Hospital Centre, Montreal, Canada Louis-H. Lafontaine Hospital, Montreal, Canada Corresponding author at: Faculty of Dental Medicine, University of Montreal, PO Box 6128, Succ. Centre-ville, Montreal (QC), Canada H3C 3J7. Tel.: +1 514 343 7126; fax: +1 514 343 2233. E-mail address: [email protected]. Philippe Girard Gilles Gauthier Faculty of Dental Medicine, University of Montreal, Montreal (QC), Canada Tania Pampoulova Louis-H. Lafontaine Hospital, Montreal, Canada Clinique Nouveau Depart, Town of Mount-Royal, QC, Canada Pierre H. Rompré Pierre de Grandmont Faculty of Dental Medicine, University of Montreal, Montreal (QC), Canada
Contents lists available at ScienceDirect
Schizophrenia Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s
Letter to the Editor Dental prosthetic rehabilitation approach in tardive dyskinesia with edentulism: A case report
Dear Editors, Tardive dyskinesia (TD) remains a prevalent and potentially disabling motor complication during chronic treatment with dopamine receptor-blocking agents (Woods et al., 2010), typically involving the bucco-linguo-masticatory musculature. As induction mechanisms remain elusive, pharmacological treatment produces mixed results. Although TD is associated with abnormal pallidothalamic outflow (Damier et al., 2007), intensity has been retrospectively reported greater with edentulism (Myers et al., 1993). Limited observations suggest that dental prosthetic rehabilitation affords relief against TD (Sutcher et al., 1998; Katz et al., 2010), along the idea to improve proprioception from the oral cavity. The objective impact of this intervention has not been quantified. We used this approach in a 66 year-old male patient with a long history of schizoaffective disorder, who provided written consent for the treatment and video recording and use. He was an active smoker with a past history of alcoholism and edentulism, and was chronically treated with monthly haloperidol i.m. injections until 3.5 years before his visit. He met the DSM-IV clinical criteria for TD but the timing of onset remained undetermined. His drug regimen included risperidone 2 mg bid, lithium carbonate 900 mg daily, procyclidine 10 mg bid, and diphenhydramine 25 mg HS. Procyclidine was weaned, but TD continued unabated. A computed tomography scan of the brain revealed a small lacune in the right lenticular nucleus with normalsized ventricles. He was wearing a worn-out upper denture only because the mandibular piece had become unstable. He was dissatisfied with his upper denture because of instability and difficulty to speak and chew properly. Jaw pain was reported. On examination, oral hygiene was deficient and a maxillary prosthetic stomatitis was documented, in addition to areas of keratosis along the mandibular alveolar ridge. Advanced mandibular bone resorption was present. His tongue was large with thrusting movements observed at rest. With his original upper denture in place or not, fairly marked stereotyped lingual and jaw dyskinesia was apparent, along with mild purposeless finger movements. Since there is no standard dental prosthetic approach to treat TD, two new sets of dentures were fabricated and adjusted. Prosthetic parameters (occlusal vertical dimension (OVD), centric relation, occlusal plane, phonetics, esthetics) were determined by two clinicians to prepare the first complete dentures. Once the patient felt comfortable, he wore them for 2 months before a self-assessment form and oral examination were completed (T1). Subsequently, he kept the new maxillary denture but another mandibular denture was prepared to arbitrarily raise the OVD by 2 mm between two points when the occluding members are in contact, to be reassessed 2 months later (T2). Videoclips of the orofacial TD movements were generated, with and without dentures in place, while the subject was 0920-9964/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2011.07.004
at rest and drawing circles on a tablet, at baseline (T0) and with each set of dentures (T1, T2). These clips were proposed to an investigator unaware of the condition of the patient, who rated them in random order along relevant orofacial items of the Tardive Dyskinesia Rating Scale [TDRS] (Simpson et al., 1979). During the rehabilitation process, jaw pain resolved and the patient reported better comfort and satisfaction, equivalent with the two new sets of dentures. The orofacial TD intensity without dentures in place was stable throughout the observation period of 6 months, with a coefficient of variation of 12.4% in video-based ratings. With the original upper denture in place at baseline (T0), orofacial TDRS scores were unchanged. However, orofacial TDRS scores were reduced by 44% (T1) and 50% (T2) relative to baseline with the new complete dentures in place (Fig. 1 and Video 1). This case of moderate orofacial TD illustrates how poorly compensated edentulism may contribute to TD intensity, and the distinct impact of dental prosthetic rehabilitation measured on a validated scale. Denture instability does not always result from uncontrollable oral TD movements and should not be necessarily viewed as an obstacle to deter such approach. We do not feel this case represents edentulous orodyskinesia, since the oral manifestations persisted at rest with the mouth kept open, were associated with involuntary extraoral movements, and did not entirely disappear upon insertion of adequate dentures (Koller, 1983; Blanchet et al., 2008). The specific OVD value reached did not seem to be a critical factor to achieve benefit. Providing proprioceptive inputs and supporting orofacial structures may be more important considerations (Sutcher et al., 1998). This interesting result confirms other clinical observations and calls for further studies measuring the
Fig. 1. Blinded, video-based, orofacial tardive dyskinesia ratings, without and with the original upper denture in place at baseline (T0), and with the two sets of dentures proposed during the rehabilitation process (T1 and T2).
Letter to the Editor
impact of proper dentures in edentulous TD subjects who are candidates for rehabilitation. Supplementary materials related to this article can be found online at doi:10.1016/j.schres.2011.07.004. Role of funding source None. Contributors PB was involved in the conception, organization, and execution of the study, and writing of the manuscript. PG was involved in the conception and execution of the study, under the supervision of GG and PdeG. TP was responsible for the video-based motor ratings, and PR analyzed them. All co-authors reviewed the manuscript. Conflict of interest All authors declare that they have no conflicts of interest that could influence this work. Acknowledgements None.
References Blanchet, P.J., Popovici, R., Guitard, F., Rompre, P.H., Lamarche, C., Lavigne, G.J., 2008. Pain and denture condition in edentulous orodyskinesia: comparisons with tardive dyskinesia and control subjects. Mov. Disord. 23, 1837–1842. Damier, P., Thobois, S., Witjas, T., Cuny, E., Derost, P., Raoul, S., Mertens, P., Peragut, J.C., Lemaire, J.J., Burbaud, P., Nguyen, J.M., Llorca, P.M., Rascol, O., French Stimulation for Tardive Dyskinesia (STARDYS) Study Group, 2007. Bilateral deep brain stimulation of the globus pallidus to treat tardive dyskinesia. Arch. Gen. Psychiatry 64, 170–176. Katz, W., Kaner, T., Carrion, J., Goldstein, G.R., 2010. The management of a completely edentulous patient with tardive dyskinesia. Int. J. Prosthodont. 23, 217–220. Koller, W.C., 1983. Edentulousness and oral dyskinesia. Am. J. Psychiatry 140, 510. Myers, D.E., Schooler, N.R., Zullo, T.G., Levin, H., 1993. A retrospective study of the effects of edentulism on the severity rating of tardive dyskinesia. J. Prosthet. Dent. 69, 578–581. Simpson, G.M., Lee, J.H., Zoubok, B., Gardos, G., 1979. A rating scale for tardive dyskinesia. Psychopharmacology (Berl) 64, 171–179. Sutcher, H., Soderstrom, J., Perry, R., Das, A., 1998. Tardive dyskinesia: dental prosthetic therapy. Panminerva Med. 40, 154–156. Woods, S.W., Morgenstern, H., Saksa, J.R., Walsh, B.C., Sullivan, M.C., Money, R., Hawkins, K.A., Gueorguieva, R.V., Glazer, W.M., 2010. Incidence of tardive
163
dyskinesia with atypical versus conventional antipsychotic medications: a prospective cohort study. J. Clin. Psychiatry 71, 463–474.
Pierre J. Blanchet Faculty of Dental Medicine, University of Montreal, Montreal (QC), Canada University of Montreal Hospital Centre, Montreal, Canada Louis-H. Lafontaine Hospital, Montreal, Canada Corresponding author at: Faculty of Dental Medicine, University of Montreal, PO Box 6128, Succ. Centre-ville, Montreal (QC), Canada H3C 3J7. Tel.: +1 514 343 7126; fax: +1 514 343 2233. E-mail address: [email protected]. Philippe Girard Gilles Gauthier Faculty of Dental Medicine, University of Montreal, Montreal (QC), Canada Tania Pampoulova Louis-H. Lafontaine Hospital, Montreal, Canada Clinique Nouveau Depart, Town of Mount-Royal, QC, Canada Pierre H. Rompré Pierre de Grandmont Faculty of Dental Medicine, University of Montreal, Montreal (QC), Canada