Dental management of the geriatric patient with major depression

Oral rehabilitation and management of mentally retarded

High level of periodontal problems of dental caries are frequently observed in mentally handicapped children. This group of patients presents various problems when they face dental treatments. Identification of such population and providing them affordable oral health care is the new concept. A systematic method for identification and screening of persons with mental retardation has been developed and is being followed. Cost and fear are the most commonly cited barriers to dental care. Physical or mental may lead to deterioration in self-care, and oral care state have a low priority. Risk factors are inter-related and are often barriers to oral health. With advancements in today's world sufficient information and support is available for each and every individual to lead a healthy life which include the access to the oral health care. Factors such as fear, anxiety and dental phobia plays a vital role in acceptance of dental care and also the delaying of dental care. Lack of knowledge of oral and dental disease, awareness or oral need, oral side-effects of medication and organization of dental services are highlighted in the literature. All health personnel should receive training to support the concept of primary oral health care. Training about dealing with such mentally handicapped people should be addressed urgently among the health professionals.

Improving oral healthcare: improving the quality of life for patients after a stroke

With the increase in the elderly population, the prevalence of systemic diseases such as strokes and heart attacks will also increase. Persons who have had a stroke will be more susceptible to mistreatment, neglect, abuse, and aspiration pneumonia. The expansion of the elderly population will make the training of professional healthcare workers and other auxiliaries extremely important. Quality of life can be maintained if poor oral health is reduced through better daily oral hygiene practices. Informing others about the known association between oral health and systemic diseases will increase the awareness of the need for good oral hygiene in order to reduce the risk of systemic diseases. Healthcare professionals must also be able to recognize, document, and report to Adult Protective Services suspected abuse such as physical and dental neglect. The networking of healthcare providers with Adult Protective Services and other professional disciplines will provide a collaborative approach to assure successful integration of healthcare protocols for the elderly population.

Oral health of psychiatric in-patients in Hong Kong

BACKGROUND

Poor oral health has been reported among various psychiatric populations. Little is known regarding the oral health among psychiatric patients in Asia.

AIMS

To examine the oral health status of a group of Chinese psychiatric in-patients in a long-term rehabilitation facility.

METHODS

A dental survey using the WHO standardised dental evaluation form was conducted in adult psychiatric patients in a rehabilitation programme. A qualified dentist examined all consenting patients.

RESULTS

Ninety-one patients (64.8% male; mean age: 44.7 +/- 9.9 years; mean length of illness: 20.3 +/- 11.5 years) were included in the study, the majority (80.2%) diagnosed with schizophrenia. Malocclusion was found in 79.1% of patients. The mean number of missing teeth was 9.5 +/- 8.9. Bleeding on probing, calculus, shallow and deep pockets were found in 7.1%, 71.8%, 72.9% and 28.2% of patients, respectively. Dental caries were found in 75.3% of dentate patients. The mean number of caries per patient was 5.5 +/- 6.1. Fifty-four per cent of patients needed dental extraction and 78.8% required conservative dental treatment. Older age and length of illness were significantly associated with poor dental health.

CONCLUSIONS

Oral health status of chronic psychiatric patients seems to be considerably worse than that of the general population. Mental health professionals should pay more attention to preventive oral health habits of psychiatric patients.

Sickle cell anemia and dental caries: a literature review and pilot study

The purpose of this cohort study was to determine whether individuals with sickle cell anemia (SCA) were more susceptible to dental caries than non-sickle-cell control subjects. A review of the literature suggests several reasons why individuals with SCA may be at increased risk. Thirty-five cases of SCA aged 6 years and older were identified from a screening of 15,900 current patient files at the Howard University College of Dentistry Dental Clinic. A total of 140 non-SCA control subjects (four per case), frequency-matched on enrollment period (+/- 5 yrs) and age (+/- 2 yrs if under age 21, or +/- 5 yrs if 21 or over), was selected by a nonbiased method from the same dental clinic files. SCA cases and controls were identical on mean age (30.4 +/- 19 yrs, ranging from 5 to 92 yrs) and were similar in sex distribution (males: 34% of SCA cases, 40% of controls). The mean number of permanent teeth present was very similar for SCA cases and controls (23.4 +/- 6.4 vs. 24.2 +/- 6.4). The mean DMFT was 21% higher in the SCA cases (12.0 +/- 8.4 vs. 9.9 +/- 6.9), and the mean DMFS was 26% higher in the SCA cases (33.0 +/- 32.3 vs. 26.2 +/- 27.7). While there was virtually no difference in DMFS between SCA cases and controls for 6- to 19-year-olds, for subjects aged 20 and older, the DMFS was 30.4% higher in the SCD cases. For all ages, the M component for SCA cases was 40.7% higher, and the D component was 20.0% higher, while the F component was only 3.5% higher than for controls. Untreated decay (the D/D+F surfaces ratio) was 24.4% higher in the SCA cases. The findings from this pilot study suggest that SCA cases have a higher susceptibility to dental caries and/or that SCA patients may have different treatment pathways once caries is detected. While none of the observed differences was statistically significant, these findings were of clinical interest and should be pursued in future large-scale studies.

Conventional and new antidepressant drugs in the elderly

Depression in the elderly is nowadays a predominant health care problem, mainly due to the progressive aging of the population. It results from psychosocial stress, polypathology, as well as some biochemical changes which occur in the aged brain and can lead to cognitive impairments, increased symptoms from medical illness, higher utilization of health care services and increased rates of suicide and nonsuicide mortality. Therefore, it is very important to make an early diagnosis and a suitable pharmacological treatment, not only for resolving the acute episode, but also for preventing relapse and enhancing the quality of life. Age-related changes in pharmacokinetics and in pharmacodynamics have to be kept into account before prescribing an antidepressant therapy in an old patient. In this paper some of the most important and tolerated drugs in the elderly are reviewed. Tricyclic antidepressants have to be used carefully for their important side effects. Nortriptyline, amytriptiline, clomipramine and desipramine as well, seem to be the best tolerated tricyclics in old people. Second generation antidepressants are preferred for the elderly and those patients with heart disease as they have milder side effects and are less toxic in overdose and include the so called atypicals, such as selective serotonin reuptake inhibitors, serotonin noradrenalene reuptake inhibitors and noradrenaline reuptake inhibitors. Monoamine oxidase (MAO) inhibitors are useful drugs in resistant forms of depression in which the above mentioned drugs have no efficacy; the last generation drugs (reversible MAO inhibitors), such as meclobemide, seem to be very successful. Mood stabilizing drugs are widely used for preventing recurrences of depression and for preventing and treating bipolar illness. They include lithium, which is sometimes used especially to prevent recurrence of depression, even if its use is limited in old patients for its side effects, the anticonvulsants carbamazepine and valproic acid. Putative last generation mood stabilizing drugs include the dihydropyridine L-type calcium channel blockers and the anticonvulsants phenytoin, lamotrigine, gabapentin and topiramate, which have unique mechanisms of action and also merit further systematic study. Psychotherapy is often used as an adjunct to pharmacotherapy, while electroconvulsant therapy is used only in the elderly patients with severe depression, high risk of suicide or drug resistant forms.

Antidepressant drugs in the elderly

1. In this article some of the most important and tolerated drugs in the elderly are reviewed. 2. Tricyclic antidepressants have to be used carefully because of their important side effects. Nortriptyline and desipramine appear to be the best tolerated tricyclics in old people. 3. Second generation antidepressants are preferred for the elderly and those patients with heart disease as they have milder side effects and are less toxic in overdose. 4. MAO inhibitors are useful drugs in resistant forms of depression in which the above mentioned drugs have no efficacy and the last generation drugs (reversible MAO inhibitors), such as moclobemide, seem to be very successful. 5. Lithium is sometimes used especially to prevent recurrence of depression, even if its use is limited in old patients due to its side effects. 6. Psychotherapy is often used as an adjunct to pharmacotherapy, while electroconvulsant therapy is used only in the elderly patients with severe depression, high risk of suicide, or drug-resistant forms.

Dental status, quality of life, and mortality in an older community population: a multivariate approach

OBJECTIVE

To evaluate the relationships between a functional measure of dental status (FDS), several variables belonging to a quality of life (QOL) profile, and mortality in an older community population.

DESIGN

Cross-sectional analysis for FDS and QOL; 10-year prospective study for mortality.

SETTING

The historical and central district of the city of Brescia, northern Italy.

PARTICIPANTS

The entire cohort of 70 to 75-year-old people living in the above-mentioned district (n = 1303): 1201 subjects were eligible for interview at baseline; 11 refused the physical examination; 52 were lost to follow-up; data are presented for the remaining sample of 1137 subjects.

MEASUREMENTS

FDS examination was used to classify the subjects into three groups: naturally adequate (ADS) (25.2%), naturally inadequate (IDS) (14.3%) dental status, and denture wearers (DW) (60.4%). Various QOL domains were assessed: mood level, cognitive status, instrumental activities of daily living (IADL), social relationships, indexes of somatic health, and health behaviors. The demographic and socioeconomic parameters were used as covariates.

RESULTS

Univariate analysis showed that both the ADS and the DW groups had a better QOL profile than the IDS group. Multiple logistic regression indicated that ADS and DW conditions were predicted independently by better educational and financial conditions, higher social relationships and a better IADL level in comparison with IDS. Moreover, compared with IDS, DS was a significant predictor of a better level at the SELF, IADL, and HCU scales whereas DW predicted only a better IADL level. Crude survival analysis showed that ADS was associated with a lower mortality risk compared with both DW and IDS, which did not differ from each other. FDS also remained a significant and independent predictor of mortality in a more general Cox's regression model.

CONCLUSIONS

Within this cohort of 70 to 75-year-old urban residents, FDS is associated with several QOL domains and with long-term survival. A hierarchy of reciprocal relationships exists among these parameters. The present study provides a basis for encouraging more extensive use of dentures. Longitudinal studies using oral health outcomes are warranted before clinical recommendations can be made.

Factors which influence the oral condition of chronic schizophrenia patients

The oral health status of 249 individuals with chronic schizophrenia was evaluated by means of the Oral Hygiene Index (OHI-S) and Decayed, Missing and Filled Teeth scores (DMFT). The patients were subdivided as to chronicity of illness and venue of psychiatric treatment (158 inpatients > 10 years' hospitalization, 34 inpatients < 10 years' hospitalization, and 57 outpatients). The severity of schizophrenia was determined by: the Brief Psychiatric Rating Scale (BPRS), the intensity of negative symptoms of schizophrenia [as measured by the Brief Psychiatric Rating Scale, Negative Symptoms (BPRSNEGS)], and the equivalent dose of chloropromazine (EDC). This study demonstrated that inpatients had greater amounts of dental disease than outpatients. The extent of dental disease among inpatients as measured by both the OHI-S and DMFT scores was directly related to the intensity of schizophrenia (BPRS), magnitude of negative symptoms associated with schizophrenia (BPRSNEGS), and length of hospitalization. DMFT scores were directly related to EDC value.