Dental Implants: A Remote Option in Case of Somatic Delusion Disorder.

A 29-year-old female was referred by a psychiatrist for dental implantation and prosthodontic rehabilitation, as she had all her healthy permanent teeth extracted within a span of 2-6 months, due to somatic delusional disorder. She presently refuses artificial dentures and implants with the fear of having worms in her teeth and the fear not yet allayed. The patient cannot be treated for her edentulous state until her psychiatric symptoms are treated. This is the limitation for the implant surgeon where service rendered is impaired in spite of advanced professional skills, ideal patient ridge, and other factors, just where the patient is not mentally prepared for the dental rehabilitation procedures.

INTRODUCTION

Psychiatric illnesses manifest as a multifaceted problem. Irrespective of the illness, it can have influence on the patient's system as a whole. The relation between dental condition and psychiatric disorders is seen to be closely related, right from the basic failure to maintain proper oral hygiene and to severe delusional ideas about teeth and obsessed concern for facial appearance (somatic delusion).

CASE REPORT

A female patient aged 29 years, who was single, accompanied by her parents, was referred by a psychiatrist for dental implantation and prosthetic rehabilitation for her edentulous state. A detailed history was elicited from her parents, and it was gathered that the patient, a graduate, developed psychiatric symptoms following family issues. A psychiatric consultation was sought earlier and she was under treatment for the past 6 years.

At the time of admission to the present mental health clinic, she presented with cardinal symptoms of schizophrenia such as auditory hallucination, delusion of reference, delusion of persecution, obsessive-compulsive features of frequent bathing, and repeatedly doing same jobs. She had disorganized behaviors such as stripping off her clothes in the public, wandering behavior, restlessness, excessive talk, and abusive and assaultive tendencies with no insight. She had also attempted suicide more than once. All these odd behaviors forced the parents to bring her to the present psychiatrist.

There is no family history of any other psychiatric illness. During the course of treatment, her mood and ideas fluctuated on and off. One such instance being she insisted on tooth extraction and threatened to commit suicide if not obliged. The patient claimed that she has been commanded by some voice to go for removal of teeth and was also deluded that her mouth was infested with worms. Meanwhile, she visited many dentists, more than ten dental surgeons, and had 7–8 healthy upper teeth extracted first, by forcing the dentist in spite of assurance by the dentist that her teeth were normal. And finally, she had all her teeth extracted over a period of 6 months [Figures 1-3].

Figure 1

Preextraction

Figure 3

Postextraction intraoral

Postextraction

She still had another somatic delusion that her nose was being drawn inside and sinking. Later in the course of illness, she said that she got all her teeth removed in response to the voice of the person. Hence, it was clear that she had communicating and commanding auditory hallucinations to which she responded.

She has been treated with antipsychotic drugs and was not administered electroconvulsive therapy as her parents were not willing for the treatment.

After total extraction of the upper teeth, she tried having dentures but she refused to wear and threw it away. At present, the patient is getting better and symptoms are under control by treatment but still she is under counseling for denture or dental implantation.

Review of literature

A review of various literature reveals documentation of patients with a known psychiatric disorders who were hospitalized and the effects of psychotropic medication on oral health, for example, temporomandibular joint disorders. Mental health problems may be manifested as the only symptom or the first one relating to oral mucosa such as facial pain, preoccupation with dentures, increased erosion, and self-inflicted injury.[1]

Self-inflicted lesions that cause mutilation are observed in schizophrenic patients. An interdisciplinary approach to self-mutilation due to psychiatric disorders was emphasized. An interaction between the two teams, dentistry and psychiatry, is very important for the improvement of the patient's condition.[23]

In addition, many patients complain of halitosis and get recurrent cleaning and scaling done, thinking their teeth are full of dirt. This sort of false belief of having a bad odor which none can perceive, neither the clinician nor the other person, is called delusional halitosis. A study was done by Akpata et al. which shows significant correlation of patients associated with oral factors and delusional halitosis.[45] Screening can be done in dental patients with comorbid mental disorders and simultaneously both can be treated.[6]

Among patients presenting for cosmetic treatments, up to 15% suffer from body dysmorphic disorder, a psychiatric condition characterized by an imagined defect in appearance with references to nose and teeth. Definitely, this proves that the preformed ideas associated with one's physical appearance is a motivating factor for undergoing certain types of cosmetic dental procedures.[7]

A proper history taking and physical examination is a must for any patient and obviously includes even noninstitutionalized psychiatric patients. Drug history is also a must. The knowledge of various side effects of the drugs should be known which commonly include dryness of mouth.[89]

DISCUSSION

Most of the patients visit the dentist due to pain and if nonorganic cannot be identified by the dentist. Hence, psychiatric training to the dentists is a must to identify them and treat. Some of the disorders are difficult to diagnose and manage by dentists. Most of the patients do visit dentist due to pain, feeling of bad smell in mouth, and unexplained vague pain in the dental and facial regions without any pathology. Phantom bite is an uncommon condition in which the patient is preoccupied with the dental occlusion. The dentist unless familiar with the signs and symptoms of these syndromes cannot do a good prosthetic practice.[1011]

Discomfort and pain that arise from psychological illness exist in association with personality and neurotic disorders. The dentist knowledge of psychiatric referral is necessary in these patients. More commonly, the family general dentist, orthodontist, oral surgeon, and periodontist are likely to come across such patients. The dental care of the psychiatric patients requires history taking and examination in the most pleasing casual environment with an emphasis on drug history. It is very important for the dentists to not assume the emotional stability of the patients. They should recognize patients with special needs such as anxiety, depression, or prior negative dental experience.[12]

Review of literature with respect to whether or not psychiatric disorders represent a contraindication to dental implant treatment is less and contradictory. A study on three patients with psychiatric disorders who were provided with dental implant-retained prostheses concluded. It is concluded that mental health disorders are not necessarily a contraindication to dental implant treatment and the same can provide valuable psychological support. If any doubt exists about the effect of a psychiatric disorder on the prognosis of implant treatment, the opinion of a psychiatrist should be obtained.[13]

In most cases of patients requesting extractions, the ethical principle of malfeasance will play a decisive role in the dentist's decision-making. In cases in which the request seems to be like a phobia delusional disorder, extraction is rarely justifiable. Dental professionals should not breach the ethics and true to their conscience not yield to greed of money or force. To aid dentists in making treatment decisions in such cases, there is a guideline that integrates possible considerations.[14]

CONCLUSION

Patients with a known mental disorder and treatment can be safely identified and treated. However in the present day, we find many people who are not identified and report to the dental outpatient clinic demanding dental treatment. Dentists, dental hygienists, dental assistants, and supportive staff members need to be aware of the particular conditions, their effects on the oral cavity, and how best to proceed with the needed care. Health educational work concerning oral health of patients should be included in psychiatric treatment, as a part of an existing therapy with the aim of improving the general quality of their life. The “doing anything is better than doing nothing” approach: this confirms the patient's belief of a disease that is nonexistent. The development of liaison psychiatry for dental hospitals should be seen as an urgent need in this context.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.