Psychosocial characteristics of oromucosal diseases in psychiatric patients: observational study from Indian dental college.

BACKGROUND: Psychiatric diseases like anxiety, depression, schizophrenia and bipolar disorders can affect the mental and physical statuses of an individual. AIM: The study was to investigate the different oromucosal diseases (OMD) in psychiatric patients and to evaluate the correlation between these OMD to severity of anxiety and depression.
MATERIALS AND METHODS: A cross-sectional study was carried out during a six-month period. Patients reporting to psychiatry department with anxiety, depression, schizophrenia and bipolar disorder as diagnosed by an experienced psychiatrist, were subjected to complete oral examination by a skilled oral diagnostician to check for OMD like oral lichen planus (OLP), aphthous stomatitis (AS) and burning mouth syndrome (BMS). During the above mentioned time interval, 1320 patients with any of the above mentioned psychiatric diseases were included in this study. Of these, 278 had anxiety, 398 had depression, 295 had schizophrenia and 349 had bipolar disorder. Equal number of individuals reported to the Oral Medicine and Radiology department for routine oral screening with no mucosal diseases were included as control group.
RESULTS: In this study, statistically significant increase in the OMD of the psychiatric patients was recorded when compared with the control group. The OMD were significantly higher in patients with anxiety (20.86%) followed by patients with depression (9.04%), schizophrenia (7.7%), bipolar disorder (7.4%) and control group (5.17%), respectively. Most prevalent OMD in patients with anxiety was AS (12%) followed by OLP (5.7%), and BMS (2.87%) respectively. Patients with moderate to severe anxiety and depression showed significantly higher prevalence of these OMD compared to the ones with mild anxiety and depression. The AS and OLP were significantly more in the younger age group (18-49 year) and BMS was higher in 50-77 year age group in both the study and control groups.
CONCLUSION: A positive association was established between psychological alterations and OMD. Emotional alterations may act as a precipitating factor that could influence the initiation and development of different OMD. Hence, better harmonization is essential between dentist and psychiatrists for comprehensive management of psychosomatic disorders of the oral mucosa.

Introduction

Psychosomatic disorders are characterized by physiological changes originating from emotional factors. Psychologically, the oral cavity is related directly or symbolically to the major human instincts and passions. Psychosomatic disorders account for around 10% of the global burden of diseases, and it may rise up to 15% by 2020.[1] These diseases cause physical and pathological changes in the body, including the oral cavity. The oromucosal diseases (OMD) with psychosomatic etiology have long been identified in medicine but so far these psychosomatic etiologies have not been confirmed. The OMD may arise as a direct expression of emotions or indirect result of psychological alterations.[23] Emotional alterations can disturb hormonal, vascular and muscular functions, which may result in physiologic changes causing pain, burning sensation, ulcerations and decreased salivation. Although a wide spectrum of psychiatric disorders affects the orofacial region, unfortunately they are often unrecognized because of the common and limited nature of their presenting features.[456] The occurrence of these OMD in psychiatric patients has not been evaluated so far, and hence in this study an attempt was made to investigate the basic data on the prevalence of OMD and their distribution among people of different ages and sex.

Materials and Methods

The present cross-sectional study was conducted at the Department of Psychiatry and Department of Oral Medicine & Radiology over a period of six months. Patients reporting to the psychiatry department for the first time and those diagnosed with anxiety, depression, bipolar disorders and schizophrenia by a senior psychiatrist were subjected to complete oral examination by a skilled oral diagnostician. A total of 1320 patients who met all the criteria were considered as study group. Similar number of individuals reported to Department of Oral Medicine and Radiology for routine oral screening with no known psychiatric disease were included as control group.

Subjects with any systemic diseases, those using tobacco and patients under treatment with psychoactive drugs were excluded from this study. Ethical clearance was obtained from the institutional ethical committee. Informed written consent was taken from all the enrolled patients.

Subjects were divided according to age as young and middle groups (18-49 years) and an older group (50-77 years). The clinical examination of the oral cavity was performed following the World Health Organization (WHO) guidelines, under artificial illumination on a dental chair, using diagnostic instruments to check for OMD.

The clinical diagnosis of the oral lichen planus (OLP) was established by the presence of a bilaterally symmetrical, lacelike gray-white, radiating reticular, annular, plaque-type lesions present at the time of the examination. Clinically diagnosed OLP were subjected to histopathological examination for confirmation.

The diagnosis of aphthous stomatitis (AS) was based on the patient's history and clinical findings. Patients reporting recurrent episodes of round or ovoid ulcers surrounded by erythematous halo and each episode of ulceration lasting for a few days to weeks were considered in this study. The ulcers had to be present at the time of the clinical examination.

Burning mouth syndrome (BMS) was recognized when oral burning or pain was present in the absence of detectable mucosal changes at the time of clinical examination.

Results

Of the 1320 patients who were selected as study group, 278 were patients with anxiety, 398 were patients with depression, 295 patients were having schizophrenia and 349 patients were reported with bipolar disorder. Out of 278 anxiety patients, 58 patients (20.86%) were having oromucosal lesions. The AS, OLP and BMS like lesions were present in 36 out of 398 patients with depression (9.04%). In the schizophrenia group, 23 out of 295 patients, (7.7%) had been diagnosed with OMD. Out of 349 bipolar disorder patients, 26 people (7.4%) had OMD. Total of 5.17% of the control group also had OMD. There was a significant increase in OMD in psychiatric patients compared with the control group.

Comparison of OMD in all groups using Chi square test revealed statistically significant (P < 0.05) results between psychiatric patients and control group. Patients with anxiety had higher OMD than patients with depression, bipolar disorder, schizophrenia and the control group. [Table 1].

Table 1

Distribution and comparison of OMD among different groups by using Chi square test

Prevalence of OMD in different group

In patients with anxiety, the prevalence of AS was 12%, OLP was 5.7% and BMS was 2.87%. While in patients with depression, the prevalence of AS was 4.02%, OLP was 2.01% and BMS was 3.01% whereas in schizophrenia patients, the prevalence of AS was 3%, OLP was 2.7% and BMS was 2%. In bipolar disorder patients, the prevalence of AS was 3.1%, OLP was 2.2% and BMS was 2%. In control group, the prevalence was 2.2%, 1.33% and 1.62% in AS, OLP and BMS, respectively [Table 2].

Table 2

Prevalence of OMD among different groups

Distribution of OMD depending on severity of anxiety and depression

Patients with moderate to severe anxiety and depression had significantly higher OMD than patients with mild anxiety and depression [Table 3].

Table 3

Distribution of OMD depending on severity of anxiety and depression

Age and gender distribution of OMD

In all the groups, OMD were significantly higher in female patients. The AS and OLP were significant in the younger age group 18-49 years, and BMS was seen in the older age group (50-77 years) [Tables 4 and 5].

Table 4

Gender-wise distribution of OMD

Table 5

Age-wise distribution different OMD

Apart from these three oral diseases, majority of the psychiatric patients also showed other OMD like chronic periodontal diseases, herpes labialis, geographic tongue, fissured tongue, dysgeusia, oral dyskinesia, angular cheilitis, lip or cheek bite and necrotizing ulcerative gingivostomatitis in order of decreasing prevalence.

Discussion

Oral psychosomatic diseases occur in response to several biochemical disorders involving neurotransmitters in the brain, incomplete connections between oral region and undefined complaints due to cognitive processes in higher centers of the brain. Several studies have attempted to elucidate the possible role of psychological state, emotional instability and personality modulation in precipitation of various OMD like AS, OLP and BMS, but no study has explored the prevalence of OMD in psychiatric conditions like anxiety, depression, schizophrenia and bipolar disorder.[24] It is proposed that psychological disturbances procreate the development and worsening of the oral diseases. Psychological alterations establish its impact on body by the multidirectional and close interrelations among the nervous, immune and endocrine system.[45]

It has been noted that OMD frequently undergo periods of remissions and exacerbations that often clearly relate to the patients emotional status.[4] Since the oral mucosa is extremely complex and highly reactive to psychological influences, oral symptoms are the common psychosomatic manifestations.[7] Many studies have evaluated the prevalence of different OMD in general population. Few researchers have evaluated the stress, anxiety and depression levels in patients suffering from oral diseases. They concluded that significantly higher stress, anxiety and depression levels were found in the AS, BMS and OLP patients when compared to control groups.[3589]

Dangore-Khasbage et al. evaluated the prevalence of AS, BMS, and OLP in institutionalized and non-institutionalized psychiatric patients and found that the prevalence of AS, BMS, and OLP was 19.33%, 20.66% and 5.3%, respectively, in all psychiatric patients.[1] In the present study prevalence rate was lesser because we considered only new psychiatric patients who were not under any previous medication. Shah et al. reported that the high prevalence of AS, BMS and OLP in psychiatric patients, can be attributed to the increased psychological stress that modifies immunological functions.[10] Psychological investigations have reported that the oral mucosa is a complex and vulnerable region that is very reactive to certain psychological influences. Hence, on the basis of the available literature, the reasons for increased prevalence of AS, BMS and OLP in psychiatric patients may be multiple and involve the interaction of biological and psychological systems.[7]

McCartan et al. conducted comprehensive reviews of OLP in the period 1980-2007. An overall age-standardized prevalence of 1.27% (0.96% in men and 1.57% in women) was calculated from their study.[11]

A more recent Indian study by Saraswathi et al reported a prevalence of 0.15% for OLP.[12] Another survey by Mathew et al. reported a prevalence of 1.2% in South Indian population.[9] Many previous studies reported prevalence of 1 to 2% in general population.[68] However the prevalence rate of OLP in our study was found to be higher than reported by the above mentioned studies. In the present study, the prevalence of AS was 12% in anxiety group, 4.02% in depression group, 3%, in schizophrenia group, 3.1%, in bipolar disorder patients and 2.2% in control group thereby suggesting a higher prevalence rate than that reported in the previous studies by Mathew et al. (2.01%),[9] Rivera-Hidalgo et al. (0.89%)[13] and Chattopadhyay.[14]

In regard to AS, prevalence rate observed in the present study was lower than that reported by most of the previous studies. The occurrence of AS in general population ranges between 5% and 20%.[6] A latest survey by Davatchi et al. in Tehran revealed a prevalence rate of 25.2%.[15] Szponar et al. in their 10-year retrospective observations reported a prevalence of 7.6%.[16]

A most recent survey of the Jordanian population reported a prevalence of about 78%.[17]

The severity and frequency of the episodes vary on a case-by-case basis; however, it usually decreases with age. Many epidemiologic studies and our own observations confirmed the higher incidence of AS in people with higher psychological alterations.

The prevalence rate of BMS observed in the present study was higher than 0.7% as reported by Lipton and Ship.[18] Bergdahl and Anneroth 0.8%.[19] Baharvand et al. 1.3%.[20] but researchers like Basker and Hakeberg 4.6%,[21] Bergdahl and Bergdahl, 3.7%.[22] and Femiano et al, 13%.[23] have reported a higher prevalence rate.

Prevalence of BMS in menopausal women were 22.7% and 4.8% in non-menopausal women.[24] which is relatively high and in accordance with Bergdahl and Bergdahl, Hackerberg et al, Savage et al,[25] and Scala et al.[26]

The lower prevalence of BMS in this study may be attributed to the wide range of age of the patients in both sexes. When BMS was identified only on the basis of a prolonged burning sensation of the oral mucosa, a prevalence rate of 14.8% was estimated.[27] However, when diagnosis was arrived at by the use of more correct criteria, BMS prevalence fell to 0.8%.[19] In the present study psychological component in BMS has been identified. This is supported by studies that report greater levels of depression and anxiety in patients with BMS compared to control groups.

Conclusion

Oral health is of great importance for psychiatric patients given their propensity to neglect it. It is the responsibility of the dentist to effectively provide adequate dental treatment for people with psychiatric disabilities. The results of the present study provide information on the distribution of OMD in psychiatric and general population. Oral lesions are detected more often in psychiatric patients than the healthy individuals with a sound mind. In addition to this fact a dental professional should also consider the possibility of psychosomatic factor in case of AS, OLP and BMS and appropriate referral should be accordingly considered.