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The dental management of patients with bipolar disorder
The dental management of patients with bipolar disorder Arthur
A. Friedlander,
D.D.S.,*
and Norman
Q. Brill, M.D.,**
Los Angeles, Calif:
Bipolar disorder (manic depressive disease) affects 1% of the United States population. These persons suffer from prolonged episodes of extreme elation and depression. There is a significant incidence of dental pathosis and a need for dental care among these patients. The medications used for the treatment of this disease, their physiologic effects, and their interactions with the drugs used in dentistry are reviewed. (ORAL
SURC.
ORAL
MED.
ORAL
PATHOL.
61579~581,
1986)
I
n American society, severe emotional illness is a relatively frequent occurrence. One percent of the American public suffers from bipolar disorder (manic depressive disease).’ The Diagnostic and Statistical Manual of Mental Disorders (DSM 111)’ defines this malady as one of a group of affective (outward manifestation of a person’s feelings, tone, or mood) disorders in which the patient suffers from prolonged episodes of extreme elation and depression. Improved modalities of treatment have allowed some patients to be treated on an ambulatory basis and have reduced the length of hospitalization for others. These patients frequently have a significant incidence of dental pathosis. The development and execution of a comprehensive dental treatment plan require an understanding of the psychopathosis involved and the psychiatric care that these patients are receiving. Hippocrates introduced the terms mania and melancholia (depression), and his descriptions are still considered clinically valid today. Aretaeus, the Roman physician, recognized that mania and depression frequently coexisted in the same person. Today psychiatrists recognize three types of bipolar disorders. In the manic type there is a history of one or
*Chief, Dental Service, Brentwood Division, West Los Angeles Veterans Administration Medical Center, and Associate Professor of Oral and Maxillofacial Surgery, School of Dentistry, University of California at Los Angeles. **Director of Continuing Medical Education, Brentwood Division, West Los Angeles Veterans Administration Medical Center; Professor Emeritus and Founding Chairman, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of California at Los Angeles.
more manic episodes. The predominant mood is elation (euphoria, unusual cheerfulness) recognized as excessive (by those who know the person well) and expansive (an unceasing and unselective enthusiasm for interacting with other persons and the environment). In the mixed type there is a history of episodes of mania and depression intermixed or rapidly alternating every few days. In the depressed type there are recurrent severe depressive episodes as the dominant feature, but there is a history of one or more manic episodes. Prevalence rates for the disorder are not affected by sex, race, religion, or marital status. However, a significant proportion of patients are found among creative writers, artists, successful professional persons, and others from upper socioeconomic groups. Biologic abnormalities (sulcal and ventricular enlargement of the brain) and hormonal disturbances have been implicated as contributing factors in the development of the disease. Eighteen percent of the patients receiving 80 mg or more of prednisone a day develop a major mental disturbance. The most common disturbance is euphoria, but severe mania or severe depression may occur. There is a strong familial pattern to this disease, with supportive evidence of genetic transmission. Twin studies show that monozygotes have a 400% greater incidence of the disease than do dizygotes. The first manic episode typically occurs in late adolescence or the early 20s. Episodes of illness last approximately 3 months at a time and may recur every 3 to 9 years. Manic episodes tend to be of shorter duration than depressive ones. With increasing age, the interval between episodes becomes shorter and the length of each episode increases. 579
580
Friedlander
and Brill
Oral June,
During periods of mania there is generally a hyperactivity, which involves excessive participation in multiple activities (for example, sexual, occupational, political, religious). There is an intrusive and demanding nature to the activities, which goes unrecognized by the patient. Frequently the patient may dress in flamboyant, colorful, or strange clothing and distribute money or advice to strangers. Pressured speech is common; it is loud, rapid, and difficult to interrupt. The speech is theatrical and dramatic, and there are abrupt changes in topic (“flight of ideas”). These persons are easily distracted and display grandiose delusions in which they claim a special relationship to God or some well-known figure from the political or entertainment world. They may go for days with little or no sleep and yet not appear tired. Lability of mood, with rapid shifts to anger or depression, is common. Untreated persons with bipolar disorder have more depressive episodes than manic episodes. Their symptoms are identical to those of persons with a major depression (unipolar) disorder. There is a loss of interest or pleasure in almost all daily activities. This may be associated with a loss of appetite and a loss of weight, sleep disturbance (usually insomnia), and decreased energy. The person will appear sad (frequently tearful) and express feelings of worthlessness, hopelessness, and guilt. The person will also have difficulty with memory and concentration and will be easily distracted and indecisive. During both manic and depressive episodes there is significant impairment in both social and occupational functioning and a need for protection from the consequences of poor judgment, hyperactivity, and the predilection to violent acting out. Usually, functioning returns to the premorbid level between episodes. Unfortunately, approximately 30% of cases run a chronic course, with residual symptomatic and social impairment (marital instability, alienation from family, job loss). The most common complications of a manic episode are substance abuse and the consequences of actions resulting from impaired judgment, such as financial losses and illegal activities. The most common complication of an episode of depression is suicide. PSYCHIATRIC
THERAPEUTIC
CONSIDERATION
Both lithium carbonate and the neuroleptics (phenothiazine family of drugs) are effective in treating the manic phase of a bipolar disorder. The majority of psychiatrists consider lithium the drug of choice because of its greater degree of specificity and the fact that it produces neither depression, sedation, nor tardive dyskinesia. Its mechanism of action as a
Surg. 1986
mood-stabilizing agent remains unknown3 but it is effective in combating current episodes of mania and in preventing future manic and depressive relapses. It has a slow onset of action, and patients may require 7 to 12 days to obtain the maximum effect. Poor patient compliance is the most common cause for failure of lithium prophylaxis. Lithium may adversely affect the central nervous system (anxiety, cognitive and memory impairment, tremors), depress thyroid function, and cause skin eruptions. Of greater clinical significance is the damage it may cause to the kidney, impairing both tubular and glomerular functioning. It may also cause a benign change in the electrocardiogram (T wave flattening or inversion) as the lithium ion displaces intracellular potassium. Depressive episodes of this disorder are frequently treated by the temporary administration of antidepressants. Care must be taken, however, for when tricyclic antidepressants are used in patients with bipolar disorders, mania can result. In addition to the medical therapeutic regimen, these patients require psychosocial intervention to help them make appropriate corrections in lifestyle. A strong and supportive social network also often militates against relapse. DENTAL
THERAPEUTIC
CONSIDERATIONS
At our institution we see numerous patients during periods of acute mania whose oral mucosae and gingivae are severely abraded, and on occasion lacerated, secondary to overvigorous use of oral health devices (toothbrush, dental floss, and interdental stimulators). We have also noted a positive correlation between the incidence and severity of cervical tooth abrasion and the frequency and length of manic episodes. During depressive episodes there is significant impairment in personal hygiene, with almost total disregard of proper oral hygiene. Patients tend to ignore dental caries and ill-fitting dentures, and they may have significant periodontal disease.4 During the depressive phase of the disease, some patients may manifest various facial pain syndromes of unknown cause. These frequently disappear when the patient receives an antidepressant drug or experiences a spontaneous mood swing to mania (hypomania or euphoria). Persons on long-term lithium therapy frequently complain of a generalized stomatitis and concurrent xerostomia. The use of artificial salivary products have made these patients more comfortable and thus better able to tolerate therapeutic levels of lithium. Adverse interactions between dental medications and lithium have not been reported. For those
Volume Number
61 6
Dental management
patients receiving neuroleptic medication (phenothiazine family) for the manic phase of the disorder, dentists must be aware of the fact that these drugs may depress the hematopoietic system with a consequent decrease in the number of red and white blood cells and platelets. This family of medications also causes fluctuations in blood pressure. Sedative medications used in dentistry may also be potentiated by this group of drugs, with a resultant severe respiratory depression. The small amounts of epinephrine used in conjunction with dental anesthetic agents produce no adverse effects in the normotensive patient being treated with neuroleptics.5 For the patients in the severe throes of the depressive phase of their disorder who are receiving tricyclic antidepressants, dental sedative medications must be avoided. The interaction between these two classes of drugs can result in severe respiratory depression. Use of local anesthetics containing epinephrine is controversial. Some authors warn of the dangers of a severe hypertensive crisis,6 while others believe this not to be clinically relevant.7 Our approach has been to use epinephrine-containing medications for their more potent anesthetic effects
of patients
with bipolar
disorder
581
but to limit the dosage and to make sure that an intravascular injection has been avoided. REFERENCES
1. Kaplan 2.
3.
4. 5.
6.
I.
HI, Sadock BJ: Comprehensive textbook of psychiatry, ed. 4, Baltimore, 1985, Williams & Williams Company, pp. 160-765. Spitzer RL (editor): Diagnostic and statistical manual of mental disorders, ed. 3, Washington, D.C., 1980, American Psychiatric Association, pp. 205-224. Goodman LS, Gilman A: The pharmacological basis of therapeutics, ed. 7, New York, 1985, Macmillan Publishing Company, pp. 426-432. Kiyak HA: Psychiatric disorders in the elderly: the dentist’s role. Spec Care Dentist 3: 8-12, 1983. Jastak JT, Yagiela JA: Vasoconstrictors and local anesthesia: a review and rationale for use. J Am Dent Assoc 107: 623-630, 1983. Boakes JL: Adverse reactions to local anesthetics/vasoconstrictor preparations: a study of the cardiovascular response. Br Dent J 133: 137-140, 1972. Hollister LE: Tricyclic antidepressants. N Engl J Med 299: 1168-l 172, 1978.
Reprint requests to: Dr. Arthur H. Friedlander Chief, Brentwood Dental Service West Los Angeles Veterans Administration 11301 Wilshire Blvd. Los Angeles, CA 90073
Medical
Center
A. Friedlander,
D.D.S.,*
and Norman
Q. Brill, M.D.,**
Los Angeles, Calif:
Bipolar disorder (manic depressive disease) affects 1% of the United States population. These persons suffer from prolonged episodes of extreme elation and depression. There is a significant incidence of dental pathosis and a need for dental care among these patients. The medications used for the treatment of this disease, their physiologic effects, and their interactions with the drugs used in dentistry are reviewed. (ORAL
SURC.
ORAL
MED.
ORAL
PATHOL.
61579~581,
1986)
I
n American society, severe emotional illness is a relatively frequent occurrence. One percent of the American public suffers from bipolar disorder (manic depressive disease).’ The Diagnostic and Statistical Manual of Mental Disorders (DSM 111)’ defines this malady as one of a group of affective (outward manifestation of a person’s feelings, tone, or mood) disorders in which the patient suffers from prolonged episodes of extreme elation and depression. Improved modalities of treatment have allowed some patients to be treated on an ambulatory basis and have reduced the length of hospitalization for others. These patients frequently have a significant incidence of dental pathosis. The development and execution of a comprehensive dental treatment plan require an understanding of the psychopathosis involved and the psychiatric care that these patients are receiving. Hippocrates introduced the terms mania and melancholia (depression), and his descriptions are still considered clinically valid today. Aretaeus, the Roman physician, recognized that mania and depression frequently coexisted in the same person. Today psychiatrists recognize three types of bipolar disorders. In the manic type there is a history of one or
*Chief, Dental Service, Brentwood Division, West Los Angeles Veterans Administration Medical Center, and Associate Professor of Oral and Maxillofacial Surgery, School of Dentistry, University of California at Los Angeles. **Director of Continuing Medical Education, Brentwood Division, West Los Angeles Veterans Administration Medical Center; Professor Emeritus and Founding Chairman, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of California at Los Angeles.
more manic episodes. The predominant mood is elation (euphoria, unusual cheerfulness) recognized as excessive (by those who know the person well) and expansive (an unceasing and unselective enthusiasm for interacting with other persons and the environment). In the mixed type there is a history of episodes of mania and depression intermixed or rapidly alternating every few days. In the depressed type there are recurrent severe depressive episodes as the dominant feature, but there is a history of one or more manic episodes. Prevalence rates for the disorder are not affected by sex, race, religion, or marital status. However, a significant proportion of patients are found among creative writers, artists, successful professional persons, and others from upper socioeconomic groups. Biologic abnormalities (sulcal and ventricular enlargement of the brain) and hormonal disturbances have been implicated as contributing factors in the development of the disease. Eighteen percent of the patients receiving 80 mg or more of prednisone a day develop a major mental disturbance. The most common disturbance is euphoria, but severe mania or severe depression may occur. There is a strong familial pattern to this disease, with supportive evidence of genetic transmission. Twin studies show that monozygotes have a 400% greater incidence of the disease than do dizygotes. The first manic episode typically occurs in late adolescence or the early 20s. Episodes of illness last approximately 3 months at a time and may recur every 3 to 9 years. Manic episodes tend to be of shorter duration than depressive ones. With increasing age, the interval between episodes becomes shorter and the length of each episode increases. 579
580
Friedlander
and Brill
Oral June,
During periods of mania there is generally a hyperactivity, which involves excessive participation in multiple activities (for example, sexual, occupational, political, religious). There is an intrusive and demanding nature to the activities, which goes unrecognized by the patient. Frequently the patient may dress in flamboyant, colorful, or strange clothing and distribute money or advice to strangers. Pressured speech is common; it is loud, rapid, and difficult to interrupt. The speech is theatrical and dramatic, and there are abrupt changes in topic (“flight of ideas”). These persons are easily distracted and display grandiose delusions in which they claim a special relationship to God or some well-known figure from the political or entertainment world. They may go for days with little or no sleep and yet not appear tired. Lability of mood, with rapid shifts to anger or depression, is common. Untreated persons with bipolar disorder have more depressive episodes than manic episodes. Their symptoms are identical to those of persons with a major depression (unipolar) disorder. There is a loss of interest or pleasure in almost all daily activities. This may be associated with a loss of appetite and a loss of weight, sleep disturbance (usually insomnia), and decreased energy. The person will appear sad (frequently tearful) and express feelings of worthlessness, hopelessness, and guilt. The person will also have difficulty with memory and concentration and will be easily distracted and indecisive. During both manic and depressive episodes there is significant impairment in both social and occupational functioning and a need for protection from the consequences of poor judgment, hyperactivity, and the predilection to violent acting out. Usually, functioning returns to the premorbid level between episodes. Unfortunately, approximately 30% of cases run a chronic course, with residual symptomatic and social impairment (marital instability, alienation from family, job loss). The most common complications of a manic episode are substance abuse and the consequences of actions resulting from impaired judgment, such as financial losses and illegal activities. The most common complication of an episode of depression is suicide. PSYCHIATRIC
THERAPEUTIC
CONSIDERATION
Both lithium carbonate and the neuroleptics (phenothiazine family of drugs) are effective in treating the manic phase of a bipolar disorder. The majority of psychiatrists consider lithium the drug of choice because of its greater degree of specificity and the fact that it produces neither depression, sedation, nor tardive dyskinesia. Its mechanism of action as a
Surg. 1986
mood-stabilizing agent remains unknown3 but it is effective in combating current episodes of mania and in preventing future manic and depressive relapses. It has a slow onset of action, and patients may require 7 to 12 days to obtain the maximum effect. Poor patient compliance is the most common cause for failure of lithium prophylaxis. Lithium may adversely affect the central nervous system (anxiety, cognitive and memory impairment, tremors), depress thyroid function, and cause skin eruptions. Of greater clinical significance is the damage it may cause to the kidney, impairing both tubular and glomerular functioning. It may also cause a benign change in the electrocardiogram (T wave flattening or inversion) as the lithium ion displaces intracellular potassium. Depressive episodes of this disorder are frequently treated by the temporary administration of antidepressants. Care must be taken, however, for when tricyclic antidepressants are used in patients with bipolar disorders, mania can result. In addition to the medical therapeutic regimen, these patients require psychosocial intervention to help them make appropriate corrections in lifestyle. A strong and supportive social network also often militates against relapse. DENTAL
THERAPEUTIC
CONSIDERATIONS
At our institution we see numerous patients during periods of acute mania whose oral mucosae and gingivae are severely abraded, and on occasion lacerated, secondary to overvigorous use of oral health devices (toothbrush, dental floss, and interdental stimulators). We have also noted a positive correlation between the incidence and severity of cervical tooth abrasion and the frequency and length of manic episodes. During depressive episodes there is significant impairment in personal hygiene, with almost total disregard of proper oral hygiene. Patients tend to ignore dental caries and ill-fitting dentures, and they may have significant periodontal disease.4 During the depressive phase of the disease, some patients may manifest various facial pain syndromes of unknown cause. These frequently disappear when the patient receives an antidepressant drug or experiences a spontaneous mood swing to mania (hypomania or euphoria). Persons on long-term lithium therapy frequently complain of a generalized stomatitis and concurrent xerostomia. The use of artificial salivary products have made these patients more comfortable and thus better able to tolerate therapeutic levels of lithium. Adverse interactions between dental medications and lithium have not been reported. For those
Volume Number
61 6
Dental management
patients receiving neuroleptic medication (phenothiazine family) for the manic phase of the disorder, dentists must be aware of the fact that these drugs may depress the hematopoietic system with a consequent decrease in the number of red and white blood cells and platelets. This family of medications also causes fluctuations in blood pressure. Sedative medications used in dentistry may also be potentiated by this group of drugs, with a resultant severe respiratory depression. The small amounts of epinephrine used in conjunction with dental anesthetic agents produce no adverse effects in the normotensive patient being treated with neuroleptics.5 For the patients in the severe throes of the depressive phase of their disorder who are receiving tricyclic antidepressants, dental sedative medications must be avoided. The interaction between these two classes of drugs can result in severe respiratory depression. Use of local anesthetics containing epinephrine is controversial. Some authors warn of the dangers of a severe hypertensive crisis,6 while others believe this not to be clinically relevant.7 Our approach has been to use epinephrine-containing medications for their more potent anesthetic effects
of patients
with bipolar
disorder
581
but to limit the dosage and to make sure that an intravascular injection has been avoided. REFERENCES
1. Kaplan 2.
3.
4. 5.
6.
I.
HI, Sadock BJ: Comprehensive textbook of psychiatry, ed. 4, Baltimore, 1985, Williams & Williams Company, pp. 160-765. Spitzer RL (editor): Diagnostic and statistical manual of mental disorders, ed. 3, Washington, D.C., 1980, American Psychiatric Association, pp. 205-224. Goodman LS, Gilman A: The pharmacological basis of therapeutics, ed. 7, New York, 1985, Macmillan Publishing Company, pp. 426-432. Kiyak HA: Psychiatric disorders in the elderly: the dentist’s role. Spec Care Dentist 3: 8-12, 1983. Jastak JT, Yagiela JA: Vasoconstrictors and local anesthesia: a review and rationale for use. J Am Dent Assoc 107: 623-630, 1983. Boakes JL: Adverse reactions to local anesthetics/vasoconstrictor preparations: a study of the cardiovascular response. Br Dent J 133: 137-140, 1972. Hollister LE: Tricyclic antidepressants. N Engl J Med 299: 1168-l 172, 1978.
Reprint requests to: Dr. Arthur H. Friedlander Chief, Brentwood Dental Service West Los Angeles Veterans Administration 11301 Wilshire Blvd. Los Angeles, CA 90073
Medical
Center