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Year : 2006  |  Volume : 17  |  Issue : 4  |  Page : 171-177
Oral health status and treatment needs in institutionalized psychiatric patients : One year descriptive cross sectional study


Department of Preventive and Community Dentistry, College of Dental Sciences, Davangere, Karnataka, India

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   Abstract 

BACKGROUND AND OBJECTIVES : Psychiatric patients are one of the special groups requiring attention as they are often neglected. Oral health is an major determinant of general health for psychiatric patients and may have a low priority in the context of mental illness. The present study was conducted to assess the oral health status and treatment needs of institutionalized psychiatric patients of Davangere. METHODS : 220 psychiatric patients admitted in two general hospitals of Davangere during the period of one year were included in the study. The oral health status was evaluated with respect to caries, oral hygiene, and periodontal status. RESULTS : Of the 180 examined with the response rate of 81.8%. 58.3% were males, mean age was 36.7 years, 57.8% had < 1 year of mental illness with a mean of 2.2 years, and 90% were self-sufficient. The multiple logistic regression analysis showed that the mean DMFT (0.92) increased with age, duration of mental illness, and irregularity of oral hygiene habits (P<0.001). Mean OHI-S score was 3.3 and multiple logistic regression analysis showed that the mean OHI-S score increased with age (P<0.001). The multiple logistic regression analysis showed that the CPI score increased with age, duration of mental illness, and degree of helplessness (P<0.001). INTERPRETATION AND CONCLUSION : The findings of this study demonstrates low caries prevalence, poor oral hygiene, and extensive unmet needs for dental treatment.

Keywords: Dental caries, oral hygiene, periodontal health, psychiatric patients, treatment needs, Davangere.

How to cite this article:
Kumar M, Chandu G N, Shafiulla M D. Oral health status and treatment needs in institutionalized psychiatric patients : One year descriptive cross sectional study. Indian J Dent Res 2006;17:171-7

How to cite this URL:
Kumar M, Chandu G N, Shafiulla M D. Oral health status and treatment needs in institutionalized psychiatric patients : One year descriptive cross sectional study. Indian J Dent Res [serial online] 2006 [cited 2014 Sep 1];17:171-7. Available from: http://www.ijdr.in/text.asp?2006/17/4/171/29868

   Introduction Top


Mental illness affects people of all nations and at all economic levels. One of the primary targets of the health of a nation should be to improve the health and social functioning of mentally ill people. Psychiatric disorders affect the general behavior of a person, impair level of functioning, and alter perception. This group is often neglected because of ignorance, fear, stigma, misconception, and negative attitudes.

There are several factors that contribute to poor oral health in patients with psychiatric disorders. These include saliva reducing medications being taken, poor diet, and apathetic nature of many psychiatric patients [1]. The most common side effect of the psychotherapeutic medications is the reduction in salivary secretions, leading to a wide array of oral diseases [2],[3],[4],[5]. Sialorrhea, dysphagia, sialadenitis, dysguesia, stomatitis, gingivitis, glossitis, tongue edema, discolored tongue, and bruxism are other complications reported [6],[7]. Studies on psychiatric patients have shown a relatively high frequency of non-compliance with oral health practices, which represent a major problem in dental care for hospitalized psychiatric patients [8]. Reports have indicated that the oral health ofpsychiatric patients is poor and have largeunmettreatmentneeds [9],[10],[11],[12].

Among the unique population groups deserving special attention are patients with psychiatric and mental disorders. To date, only few studies have been conducted to determine the oral health status and treatment needs of institutionalized psychiatric patients in India [11],[12]. Since very few data are available, this study was undertaken with the following objectives:

  1. To determine the oral health status of institutionalized psychiatric patients in Davangere, Karnataka.
  2. To assess the treatment needs of institutionalized psychiatric patients in Davangere, Karnataka.



   Materials and methods Top


Psychiatric patients are catered in 2 hospitals of Davangere city namely Bapuji Hospital and Chigateri General Hospital. All the 220 psychiatric patients with an age range of 15 to 80 years who were admitted in these two hospitals during the period of one year that is 1st January 2004 to 31st December 2004 were included in the study. However, patients with advanced dementia, those who were aggressive and unco-operative, and severely disabled patients were excluded from the study due to their limited ability to co-operate.

Ethical clearance was obtained from the Ethical Committee of College of Dental Sciences, Davangere and official permission was obtained from the in charge of the two hospitals to carry out the study.

A specially designed proforma was used for recording details in the study. The proforma consisted of two parts, the first part pertaining to the questionnaire that included information on demographic and medical variables. Demographic and medical data were retrieved from clinical records and integrated through interviews with the psychiatrist in charge. The demographic variables considered were age, sex, and duration of mental illness. The medical variables included degree of helplessness, diagnosis of mental disorders, and medication used. The diagnosis of mental disorders was reviewed from clinical records in accordance with International Classification of Diseases. [ICD- 10 classification] [13].

Information was also collected on psychiatric patient's oral hygiene practices from the attendant of the patient. The second part consisted of recording information on clinical information.

Examination procedure

Throughout the study only one examiner conducted the examination and the assistant, who was trained, recorded the data. The examination was conducted in the hospital wards with the patient sitting upright in his bed facing natural light, and for those who were partially / totally helpless, examination was conducted with the patient lying on the bed.

Dental caries was recorded using Decayed, Missing and Filled Teeth (DMFT) and Decayed, Missing and Filled Surfaces (DMFS) indices [14]. The diagnosis of dental caries was done using the WHO 1999 criteria [15].

Oral hygiene status was recorded using Simplified Oral Hygiene Index [OHI-S] [16] and periodontal status by CommunityPeriodontal Index [CPI] [15].

The data obtained was subjected to statistical analysis.


   Statistical analysis Top


The data collected was analyzed using Analysis of Variance (ANOVA), Chi-square test and Multiple Logistic Regression Analysis. Three models were developed to determine variables that were significantly associated with the following outcomes of interest DMFT, OHI-S and CPI. In all models, the explanatory variables included were the following

i) Sex

ii) Age

iii) Degree of helplessness

iv) Duration of mental illness

v) Diagnosis

vi) Oral hygiene practices

p < 0.05 was accepted as statistically significant and p < 0.01 was set to be highly statistically significant. The statistical analysis was performed using the SPSS package and MINITAB (Version IV, USA).


   Results Top


Out of the total study population of 220 psychiatric patients, 29 were too ill or were unco-operative or were aggressive and 11 refused to participate in the study, hence only 180 participated with a response rate of 81.8%.

[Table - 1] shows the profile of the study group. 15-24 year age group had the highest proportion of psychiatric patients. 57.8% of the patients had <1 year of mental illness. 45% of the patients were diagnosed with mood disorders.

The mean DMFT and DMFS scores were 0.92±1.8 and 2.54±5.0 respectively [Table - 2]. There were 118 caries free patients, with caries prevalence of 32.2%.

The mean OHI-S score was found to be 3.3. The DI-S, CI­S and OHI-S score increased progressively with age [Table - 3].

[Table - 4]A and [Table - 4]B illustrates the periodontal status among the study population. Healthy gingiva was seen in only 19% of the study population and with increasing age, gingivitis progressed to periodontitis.

Multiple logistic regression analysis for the mean DMFT score increased with age, duration of mental illness, and in those who irregularly cleaned their teeth (P<0.001) [Table - 5].

Multiple logistic regression analysis for the mean OHI-S increased with age (P<0.001) [Table - 6].

[Table - 7] shows that multiple logistic regression analysis for the CPI scores increased with age, duration of mental illness, and among those who were partially or totally helpless (P<0.001).

[Table - 8] presents the treatment needs among psychiatric patients of Davangere. Patients in >55 year age group were in higher need of complex periodontal therapy (32.3%) than any other group.

3.3% were edentulous, out of which 4 were partially or totally helpless and 2 were self-sufficient. 41.3% had one or more missing teeth. But none of them had any prosthesis.


   Discussion Top


The present study was conducted to assess the oral health status and treatment needs among psychiatric patients of Davangere city. As these patients lack finger dexterity, physical ability, and mental capacity to perform oral hygiene procedures, the oral health status of the underprivileged population is very poor.

The principle findings of this study were low caries prevalence, poor oral hygiene status and high prevalence ofperiodontal disease.

Caries status

The caries prevalence was found to be very low in the present study with mean DMFT and DMFS scores to be 0.92+1.8 and 2.54+5.0 respectively. Other studies conducted among psychiatric patients reported a higher prevalence. Vigild M et al [17] reported mean DMFT of 26.1, 15.5 by Angelillo IF et al [10], 12.8 by Kenkre AM and Spadigam AE [11], 19.1 by Lewis S et al [1], 6.1 by Rekha R et al [12]. The probable explanation for the caries experience among the study population could be due to the water fluoride concentration of Davangere city reported to be 1.5-2PPM as per Water Quality Mapping (Chemical) conducted in the year 2001 by Bapuj i Institute of Engineering and Technology Center, Davangere.

Direct comparisons between the present study and other studies is difficult because of difference in age ranges, level of treatment available, diagnosis of psychiatric illness, and duration of illness.

More than two-thirds (67.8%) of the study population were caries-free in sharp contrast to the other studies: Vigild M et al [17] reported only 11% caries-free patients andAngelillo IF et al [10] reportedno caries free patients.

Multiple logistic regression analysis showed that the mean DMFT score increased with age consistent with other studies conducted on psychiatric patients [1],[10],[11],[12]. DMFT score also increased with duration of mental illness in accordance with other studies [9],[12],[17]. The finding that irregular tooth brushing habits lead to increased dental caries prevalence was consistent with only one study [Hede B [9]].

Oral hygiene status

The mean OHI-S was found to be 3.3 and was comparable with other studies [10],[11]. Multiple logistic regression analysis showed that with increasing age, the oral health status worsened and was in accordance with other studies [1],[10],[11].

Periodontal status

The psychiatric patients in the present study had poor periodontal status with high treatment needs; only 1.9% had healthy periodontal tissues, while bleeding on probing, calculus, shallow pockets and deep pockets were found in 10.5%, 40.6%, 35.3% and 7.8% respectively. These findings are in conformity with other studies [11],[12],[17],[18].

Multiple logistic regression analysis shows that in the present study the periodontal status worsened with increasing age, increasing duration of mental illness and among patients who were partially or totally helpless (P<0.001).

The relationship of increasing age and worsening periodontal status is reflected not only in CPI scores for pockets, but also by large number of excluded sextants because of absence of dentition due to increase in tooth loss. This is consistent with other studies [10],[11],[18].

In accordance with other studies [10],[18], our study also showed that increase in the duration of mental illness resulted in worsening of periodontal condition and tooth loss. This is likely due to the continuous neglect towards personal and oral hygiene.

Patients who were partially or totally helpless had increased periodontal scores. This was expected as the degree of helplessness worsens, the ability to perform their daily activities reduces.

Edentate subjects

Avery low percentage of psychiatric patients in this study were found to be edentulous (3.3%). But a higher percentage was found in other studies; Vigild M et al [17] reported 63%, 31.7% by Velasco and Bullon [18], 63% by Lewis S et al [1]. The low prevalence of edentulousness in the present study might be due to relatively young age (mean age 36.7 years) compared to other studies.

Treatment needs

The mean decayed teeth (DT) was found to be very low (0.6) in our study, comparable to other studies; Vigild M et al [17] reported 1.3 decayed rate and Lewis S et al [1] reported 0.9 decayed rate. 23.6% of the psychiatric patients had untreated decayed teeth and 18.9% required restorative care in accordance with the study by Lewis S et at [1].

The prevalence of missing teeth due to caries (18.9%) in the present study was found to be higher than filled teeth. The filled component was almost non-existent, as no regular treatment was available to the study population.

In the present study, 29.9% required extraction and was in accordance with other studies [1],[17]. This might be a reflection of long standing treatment needs. In contrast, other studies have reported higher prevalence of extraction needs; 80.7% byAngelillo IF et al [10], Kenkre and Spadigam [11] reported 75.6% extraction needs.

Virtually 98.1% of the patients required oral hygiene instructions and 87.6% required oral hygiene instructions and oral prophylaxis. This finding is consistent with other studies [10],[11],[12],[18]. Only 7.8% of the study population required complex periodontal therapy. This was in contrast to other studies; Angelillo IF et al [10] reported 64.8% were in need of complex periodontal therapy, whereas Lewis S et al [1] reported only 1% requiring complex periodontal therapy.


   Conclusion Top


The results of this study showed that psychiatric patients have extensive dental diseases, many of them requiring complex treatment. However, prevention should be the main objective because patients with advanced mental illness are often anxious and unco-operative in the dental clinic, thereby precluding complex treatment. No dental treatment was provided in these hospitals except referral to the dental surgeon for emergency treatment. Hence more coordinative efforts between medical, dental, and social care sectors must be established to serve the needs of this underprivileged population.

 
   References Top

1.Lewis S, Jagger G. Treasure E: The oral health of psychiatric in-patients in South Wales. Spec Care Dentist 12:182-186,2001.  Back to cited text no. 1    
2.Rundgren Jan, Van Dijken Jan, Momstad Hakan, Von Knorring Lars: Oral conditions in patients receiving long treatment with cyclic anti­depressants: SwedDentJ9: 55-64,1985.  Back to cited text no. 2    
3.Lucas VS: Association of psychotropic drugs, prevalence of denture-related stomatitis and oral candidosis. Community Dent Oral Epidemiol 21: 313-316,1993.  Back to cited text no. 3    
4.Felder SR, Millar BS, Henry HR: Oral manifestations of drug therapy. Spec Care Dentist 8: 119-123,1988.  Back to cited text no. 4    
5.Keene Jr. J, Galasko TG, Land NE: Anti-depressant use in psychiatry and medicine. Importance for dental practice. JADA 134:71-79,2003,  Back to cited text no. 5    
6.Friedlander HA and Mahler EM: Major depressive disorder. Psychopathology, medical management and dental implications. JADA 132:629-638,2001.  Back to cited text no. 6    
7.Friedlander HA, Friedlander KI, Marder RS: Bipolar I disorder. Psychopathology, medical management and dental implications. JADA 133: 1209-1217,2002.  Back to cited text no. 7    
8.Barnes PG, Allen HE, Parker AW, Lyon CT, Armentrout W, Scole J: Dental treatment needs among hospitalized adult mental patients. Spec Care Dentist 8:173-177,1988.  Back to cited text no. 8    
9.Hede B: Oral health in Danish hospitalized psychiatric patients. Community Dent Oral Epidemiol 23:44-48,1995.  Back to cited text no. 9    
10.Angelillo IF, Nobile GCA, Pavia M, De Fazio P, Puca M, AmatiA: Dental health and treatment needs in institutionalized psychiatric patients in Italy. Community Dent Oral Epidemiol 23: 360-364, 1995.  Back to cited text no. 10    
11.Kenkre AM and Spadigam AE: Oral health and treatment needs in institutionalized psychiatric patients in India. Indian Journal of Dental Research 11:5-11,2000.  Back to cited text no. 11    
12.Rekha R, Hiremath SS, Bharath S: Oral health status and treatment requirements of hospitalized psychiatric patients in Bangalore City: A comparative study. J Indian Soc Pedo Prev Dent 20: 63-67,2002.  Back to cited text no. 12    
13.WHO: International Classification of Mental and Behavioral Disorders: ICD: I Oth Edition: 1993.  Back to cited text no. 13    
14.Klein H, Palmer EC, Knutson JW: Studies on dental caries. Dental status and dental needs of elementary school children. Public Health Rep 53: 751-765, 1938.  Back to cited text no. 14    
15.WHO 1999. Oral health surveys. Basic methods. 4th edition. Geneva.  Back to cited text no. 15    
16.Greene JC and Vermilion JR: The Simplified Oral Hygienelndex. JADA68: 25-31,1964.  Back to cited text no. 16    
17.Vigild M, Brinck JJ, Christnsen J: Oral health and treatment needs among patients in psychiatric institutions for the elderly. Community Dent Oral Epidemiol21:169-171,1993.  Back to cited text no. 17    
18.Velasco E and Bullon P: Periodontal status and treatment needs among Spanish hospitalized psychiatric patients. Spec Care Dentist 19: 254-258, 1999.  Back to cited text no. 18    

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Correspondence Address:
G N Chandu
Department of Preventive and Community Dentistry, College of Dental Sciences, Davangere, Karnataka
India
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DOI: 10.4103/0970-9290.29868

PMID: 17217213

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    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8]

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