|Year : 2015 | Volume
| Issue : 2 | Page : 84-88
Association between psychosocial disorders and oral health
Amita Aditya1, Shailesh Lele2
1 Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral Medicine, College of Dentistry, King Faisal University, Saudi Arabia
|Date of Web Publication||11-Dec-2015|
Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, S. No. 44/1, Vadgaon (Budruk), Off. Sinhgad Road, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
It is a fact that mind and body share an intimate relationship. There are many ways in which mental and physical health impact each other. Psychosocial factors play a part in the pathogenesis of physical health, and oral health is no exception. Chronic and painful oral symptoms lead to psychosocial disorder and at the same time, some patients with psychosocial disorders experience painful oral and facial symptoms. Several investigators have concluded that psychosocial factors play an important role in the pathogenesis of an array of oral problems, ranging from poor oral hygiene to chronic pain disorders, such as temporomandibular joint disorders, burning mouth syndrome, and atypical pain. This review aims at the in-depth analysis of the correlation between psychosocial disorders and various oral symptoms.
Keywords: Correlation, oral health, oral symptoms, psychosocial disorders
|How to cite this article:|
Aditya A, Lele S. Association between psychosocial disorders and oral health. J Dent Allied Sci 2015;4:84-8
| Introduction|| |
"Human psychology is a subject that fascinates almost everyone because we all have notions of what's normal and what's not."
The modern era has seen an unprecedented rise in the incidence of disorders affecting the human psyche. The term "psychosocial" refers to the psychological and social factors that influence mental health. A psychosocial disorder is a mental illness caused or influenced by life experiences, as well as maladjusted cognitive and behavioral processes. This mental illness is not a single condition nor do patients suffering from such disorders form a homogeneous group in the society.  It is indeed a continuum, ranging from minor distress to severe disorders of mind and behavior. It affects people of all nations and of socioeconomic strata.
There are several factors that may contribute to poor oral health in patients with psychosocial disorders. These include saliva reducing medications being taken, poor diet, and apathetic nature of many psychiatric patients. The most common side effect of the psychotherapeutic medications is the reduction in salivary secretions, which may lead to several oral diseases. Studies on psychiatric patients have shown a relatively high frequency of noncompliance with oral health practices, which represent a major problem in dental care for hospitalized psychiatric patients. Reports have indicated that the oral health of psychiatric patients is poor and have large unmet treatment needs. The role of psychosocial disorders in the etiopathogenesis of chronic oral pain disorders still remains to be understood. The question that is often asked and rarely answered satisfactorily is whether these pain syndromes are a result or the cause behind the psychosocial disorders. If the association between these oral symptoms and the psychological status of the patients is understood; it will lead to the provision of better oral health care to this often neglected group of patients. The present review is an attempt in this direction.
| Definition and Classification|| |
American Psychiatric Association  defines mental disorder as a "clinically significant behavioral or psychological syndrome or pattern that occurs in an individual, and is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom." American Psychiatric Association distinguishes 16 different subtypes (or categories) of mental illness. Although psychosocial variables arguably have some degree of influence on all subtypes of mental illness, the major categories of mental disorders thought to involve significant psychosocial factors include:
- Substance-related disorders: Disorders related to alcohol and drug use, abuse, dependence, and withdrawal.
- Schizophrenia and other psychotic disorders: These include the schizoid disorders (schizophrenia, schizophreniform, and schizoaffective disorder), delusional disorder, and psychotic disorders.
- Mood disorders: Affective disorders such as depression (major, dysthymic) and bipolar disorders.
- Anxiety disorders: Disorders in which a certain situation or place triggers excessive fear and/or anxiety symptoms (i.e., dizziness, racing heart), such as panic disorder, agoraphobia, social phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder, and generalized anxiety disorders.
- Somatoform disorders: Somatoform disorders involve clinically significant physical symptoms that cannot be explained by a medical condition (e.g., somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder).
- Factitious disorders: Disorders in which an individual creates and complains of symptoms of a nonexistent illness in order to assume the role of a patient (or sick role).
- Sexual and gender identity disorders: Disorders of sexual desire, arousal, and performance. It should be noted that the categorization of gender identity disorder as a mental illness has been a point of some contention among mental health professionals.
- Eating disorders: Anorexia and bulimia nervosa.
- Adjustment disorders: Adjustment disorders involve an excessive emotional or behavioral reaction to a stressful event
- Personality disorders: Maladjustments of personality, including paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive personality disorder (not to be confused with the anxiety disorder OCD).
- Disorders usually the first diagnosed in infancy, childhood, or adolescence: Some learning and developmental disorders (i.e., attention-deficit/hyperactivity disorder) may be partially psychosocial in nature.
| Prevalence of Psychosocial Disorders|| |
Psychiatric epidemiology has gone through various stages of growth over the past five decades in India, starting from the first psychiatric epidemiology study by Dube in 1961 at Agra. Varying prevalence reports have been reported, ranging from 9.5 to 370/1000 population. 
Murli in 2001 conducted an epidemiological study of the prevalence of mental disorders in India, in which prevalence rates for all mental disorders was observed to be 65.4/1000 population. 
There are very few regional studies done for estimating the prevalence of psychiatric disorders. In one such study done in Pune, Maharashtra, 5.03% prevalence of diagnosable psychiatric disorders in the adult population. 
| Psychosocial Disorders and Oral Health|| |
In the 20 th century, psychoanalysts including Ferenczi, Groddeck and Adler suggested that Freud's theory of conversion of mental disorders into physical symptoms may be applied to physical illness. 
Various studies using psychological inventories or diagnostic tools of psychiatry have revealed that psychological factors can initiate, contribute to or sustain physical illnesses such as essential hypertension, migraine, peptic ulcers, psoriasis, and lichen planus. ,
Oral health is an important aspect of quality of life which affects eating, comfort, speech, appearance, and social acceptance. However, there is some evidence that patients suffering from mental disorders are more vulnerable to dental neglect and poor oral health.  There are several reports which have indicated that oral health of psychiatric patients is poor and have large unmet treatment needs. ,,
There seem to be many ways in which psychosocial health and oral health can impact each other. Some oral health problems arise from the manifestations of psychosocial illness while others may be side effects of psychiatric medications. Unfortunately, such patients also demonstrate reduced rates of compliance for preventive oral health care, as well as a reduced ability to obtain and tolerate needed oral health treatment.  In a Danish study of hospital patients with schizophrenia, the dental attendance was half that of the normal population. Tooth brushing was down by a third, indicating poorer dental health behavior. 
An association between various psychosocial disorders and certain oral symptoms has been emphasized by many investigators. In a report published by British Society for Disability and Oral Health, it was inferred that oral symptoms may be the first or sometimes the only manifestation of a mental health problem, for example, facial pain, preoccupation with dentures, excessive palatal erosion of teeth or self-inflicted injuries. 
This complex interrelationship between oral and psychosocial health has often been explained on the basis of the "biopsychosocial model" of disease. This model emphasizes how the combination of somatosensory and psychosocial input influences a patient's response to acute pain, and how a chronic stimulus contributes to the suffering and pain behavior commonly demonstrated in chronic pain conditions. 
There are certain psychosocial disorders which are reported to be associated with various oral and facial symptoms more often as compared to other disorders; for example schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and substance abuse disorder.
Various investigators have suggested that psychosocial disorders may lead to advent or aggravation of certain oral symptoms, both subjective as well as objective, in certain patients. Though the exact association is still not very clear, psychosocial disorders are speculated as one of the etiological factors in following oral symptoms.
Xerostomia, the subjective feeling of oral dryness, is primarily caused by a marked decrease in the function of salivary glands. Although not a disease, it may herald the onset, or signal the presence of a number of systemic diseases and conditions. Often considered to be common in older population, there are few studies which estimated the prevalence of xerostomia in the general population.
Xerostomia has often been reported to be associated with certain psychosocial disorders, especially anxiety and depression. In fact, most individuals have experienced a dry mouth during a period of nervous tension. The xerostomic potential of many of the psychotropic drugs is also well-documented. These drugs are known to enhance serotoninergic and/or noradrenergic mechanisms. Unfortunately, they also block histaminic, cholinergic and alpha-1-adrenergic receptor sites. This leads to the unwanted effect of xerostomia in patients taking these common antipsychotic drugs, especially antidepressants. ,,,,
These studies indicate that xerostomia could either be a result of the psychosocial disorder itself or be due to the various psychotropic drugs with xerostomic potential.
Burning mouth syndrome
Though it has been the subject of much research, burning mouth syndrome (BMS) - a chronic orofacial condition - remains a poorly understood. Numerous causes have been suggested, including systemic factors, local factors such as candidiasis and denture trauma, xerostomia, and psychogenic factors and sensory neuropathies. However, little objective data substantiate the majority of these causes. ,
The prevalence of BMS reported in the literature is 0.7-4.6% of the general population. Despite the evidence suggesting that BMS may reflect a dysfunction involving the peripheral and/or central nervous system, a common thread linking all cases of BMS is an underlying psychiatric problem that, at the very least, contributes the severity and pattern of the symptoms. 
It has been reported that psychological and psychosocial factors seem to play an important role in facial pain disorders, and psychogenic factors have been considered as the most common and major etiological factors in BMS.  Emotional factors seem to be important in patients with BMS. In fact after iron deficiency, depression is the next most frequent etiological factor. However, some investigators suggest that anxiety is the most common psychosocial disorder associated with BMS, followed by depression and neurosis. ,
Although, a higher proportion of psychological disorders in BMS patients has been reported, this finding might reflect either patient's underlying anxiety or anxiety resulting from BMS, a dilemma always present in patients with chronic pain conditions. 
Temporomandibular joint symptoms and temporomandibular disorders
Temporomandibular disorders (TMDs) constitute a complex and heterogenous group of conditions and clinical problems that involve the temporomandibular joint and the masticatory musculature. TMD are an important challenge for a dental professional due to various controversies associated with etiopathogenesis, diagnosis, and treatment.
The identification of an unambiguous universal cause for TMD is still lacking. It is considered as a multifactorial disorder that results from the existence of various contributing factors; psychosocial factors being one of them. Some studies have reported that in a significant number of patients psychosocial factors play a role in causation and maintenance of TMDs. ,,
Many investigators have demonstrated that patients with TMD differ widely with regards to levels of pain, pain-related disability and distress, but physical findings do not appear to explain these differences. Investigators have also shown that major psychosocial disorders are common among patients with TMD. Finally, psychosocial variables are associated with symptom severity, and indicators of psychosocial dysfunction are associated with worse treatment outcomes in this patient population. They concluded that taken together, these findings provide substantial empirical evidence that psychosocial factors play important roles in symptoms, symptom impact and treatment response of patients with TMD. It has also been reported that the higher prevalence of bruxism and signs of TMD in psychiatric patients is a major clinical comorbidity. 
Atypical facial pain
Originally the term "atypical facial pain (AFP)" was used to describe patients whose response to neurosurgical procedures was not "typical." The term has been considered to represent psychological disorder although no specific diagnostic criteria have ever been established. It is defined more by what it is not than by what it is. Feinmann characterized AFP as a nonmuscular or joint pain that has no detectable neurologic cause. The International Headache Society (IHS) classification (IHS 12.8) uses the term, "facial pain not fulfilling other criteria" for AFP. Atypical odontalgia, described as a chronic pain disorder characterized by pain localized to teeth or gingiva, has been considered as to be a variant of AFP. The condition has also been called "phantom tooth pain" and defined as persistent pain in endodontically treated teeth or edentate areas for which there is no explanation to be found by physical or radiographic examination. 
Atypical pain (AP) if misidentified, can lead to unnecessary, irreversible treatment. According to early reports, AP was thought to be a manifestation of the psychiatric disorder. However, recent investigations indicate that pain of in case of AP is primary neuropathic. 
Although mental illness does not cause AP, this pain disorder has been associated with depression and other psychosocial disorders, perhaps because the perception of pain is affected by the emotional state.
International Association for the Study of Pain, the leading professional organization devoted to research and management of pain has developed a new taxonomy for classifying psychogenic pain. It allows for classification of painful states in the head and orofacial region as pains of psychogenic origin when there is no physical cause of the pain, or when the painful condition stems from dysfunctional muscle group in the head or face associated with psychological disturbance. 
Though the exact dynamics is still not well-understood, the relationship between psychosocial disorders and AP could be called as "bidirectional."
Other sensory disturbances
Certain other sensory disturbances, such as aberrant taste sensation, tingling, or numbness have been reported to be directly or indirectly associated with the psychosocial disorders. They are most commonly seen to be present in association with other conditions like BMS, , or are the side effects of various psychotropic medications. ,
| Signs of Bruxism|| |
Bruxism has been defined as a diurnal or nocturnal parafunctional habit, including clenching, grinding, and bracing of the teeth that can happen consciously or unconsciously and is considered one of the most destructive habits. Psychological problems, stress, depression, hostility, and anxiety have been claimed to be related to bruxism. 
| Signs of Gastroesophageal Reflux|| |
Excessive erosion of the palatal surfaces of the maxillary anterior teeth is almost the pathognomonic manifestation of eating disorders like bulimia and anorexia nervosa. Dentists have a role in the early diagnosis of eating disorders as they may be the first to observe the effects of the illness. Anorexia nervosa is a condition involving extreme dietary restrictions which, if sustained, can lead to serious medical problems. The starvation periods are commonly interrupted by uncontrolled eating episodes. The exact etiology of this disorder has not been definitively determined, but both psychological and physiological factors are likely involved. 
Anorexia nervosa reduces serum calcium levels, predisposing to the erosion of tooth enamel and caries formation. In bulimia nervosa, large quantities of soft, sweet food is often consumed and vomited. Acidic gastric juices erode the lingual aspect of the anterior teeth. 
Certain investigators have reported that various reflux symptoms are significantly more frequent in patients with psychiatric disorders.
Piccoli et al. in 2014 reported that there is a direct correlation between tooth wear, psychiatric disorders and administration of certain drugs. Poor oral hygiene and extensive unmet needs for dental treatment were widespread among psychiatric patients. 
| Oral Mucosal Lesions|| |
The oral mucosa is thought to be highly reactive to psychological influences, and in some cases oral diseases may be a direct expression emotions or conflicts while in other instances, lesions of oral mucosa may be the indirect result of an emotional problem. 
Lesions associated with tissue abuse habits and factitial injuries have been commonly reported in patients with psychosocial disorders. 
McCarthy and Shlkar in 1980 postulated a classification of oral psychosomatic diseases: 
- Oral psychosomatic diseases.
- Aphthous stomatitis.
- Glossitis and stomatitis areata migrans.
- Oral diseases in which psychological factors may play some etiologic role.
- Erythema multiforme.
- Mucous membrane pemphigoid.
- Chronic periodontal diseases.
- Oral infections in which emotional stress serves as a predisposing factor.
- Recurrent herpes labialis.
- Necrotizing gingivitis.
- Oral diseases induced by neurotic habits.
- Biting of oral mucosa.
- Physical/mechanical irritation.
- Dental/periodontal disease produced by bruxism.
- Neurotic oral symptoms.
- Mucosal pain.
Thus, psychogenic factors have been postulated as an important aspect in the etiology of certain oral mucosal lesions such as recurrent aphthous stomatitis, lichen planus, and pemphigus. ,
| Conclusion|| |
Review of the available literature suggests that association between psychosocial disorders and oral symptoms has been speculated by many investigators in the past. There are quite a few studies conducted to assess the prevalence of psychosocial disorders in patients reporting certain oral symptoms. However, very limited data are available regarding the prevalence of these oral symptoms in the patients with psychosocial disorders. Our knowledge in this aspect still seems to be inadequate.
Needless to say that this diverse population experiences similar, or even greater, oral problems than the general population. Whether institutionalized or in the community, they are entitled to the same standard of care as the rest of the community. Oral health contributes to the general health, self-esteem and quality of life. Although oral health may get lower priority in the context of mental illness, the impact of such disorders and their treatment on oral health needs to be addressed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sadock BJ. Psychosocial treatments: General principles. In: Sadock BJ, Sadock VA, editors. Kaplan & Sadock′s Comprehensive Textbook of Psychiatry. 7 th
ed. Philadelphia: Lippincott Williams and Wilkins; 2004. p. 3112.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th
ed. Washington, DC: American Psychiatric Association; 2000.
Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res 2007;126:183-92.
Murli MS. Epidemiological study of prevalence of mental disorders in India. Indian J Community Med 2001;26:10-2.
Deswal BS, Pawar A. An epidemiological study of mental disorders at Pune, Maharashtra. Indian J Community Med 2012;37:116-21.
Anitha B, Lele S. Psychosocial and physical assessment of patients with temporomandibular disorders. JIAOMR 2004;16:19-23.
Soto Araya M, Rojas Alcayaga G, Esguep A. Association between psychological disorders and the presence of oral lichen planus, burning mouth syndrome and recurrent aphthous stomatitis. Med Oral 2004;9:1-7.
Cormac I, Jenkins P. Understanding the importance of oral health in psychiatric patients. Adv Psychiatr Treat 1999;5:53-60.
Hede B. Oral health in Danish hospitalized psychiatric patients. Community Dent Oral Epidemiol 1995;23:44-8.
Angelillo IF, Nobile CG, Pavia M, De Fazio P, Puca M, Amati A. Dental health and treatment needs in institutionalized psychiatric patients in Italy. Community Dent Oral Epidemiol 1995;23:360-4.
Lucas VS. Association of psychotropic drugs, prevalence of denture-related stomatitis and oral candidosis. Community Dent Oral Epidemiol 1993;21:313-6.
Vigild M, Brinck JJ, Christensen J. Oral health and treatment needs among patients in psychiatric institutions for the elderly. Community Dent Oral Epidemiol 1993;21:169-71.
Hede B. Dental health behavior and self-reported dental health problems among hospitalized psychiatric patients in Denmark. Acta Odontol Scand 1995;53:35-40.
Oral Health Care for People with Mental Health Problems: Guidelines and Recommendation. Report of British Society for Disability and Oral Health. Available from: www.bsdh.org.uk/guidelines/mental.pdf
Okeson JP. The psychology of pain. In: Bell′s Orofacial Pain. 5 th
ed. Chicago: Quitessence; 1995. p. 93-102.
Sreebny LM, Valdini A. Xerostomia. Part I: Relationship to other oral symptoms and salivary gland hypofunction. Oral Surg Oral Med Oral Pathol 1988;66:451-8.
Bergdahl M, Bergdahl J. Low unstimulated salivary flow and subjective oral dryness: Association with medication, anxiety, depression, and stress. J Dent Res 2000;79:1652-8.
Aditya A, Lele S. Prevalence of xerostomia and burning sensation in patients with psychosocial disorders. J Int Dent Med Res 2011;4:111-6.
Ship JA, Grushka M, Lipton JA, Mott AE, Sessle BJ, Dionne RA. Burning mouth syndrome: An update. J Am Dent Assoc 1995;126:842-53.
Grushka M. Clinical features of burning mouth syndrome. Oral Surg Oral Med Oral Pathol 1987;63:30-6.
Barker KE, Savage NW. Burning mouth syndrome: An update on recent findings. Aust Dent J 2005;50:220-3.
Bergdahl J, Anneroth G. Burning mouth syndrome: Literature review and model for research and management. J Oral Pathol Med 1993;22:433-8.
Hampf G, Vikkula J, Ylipaavalniemi P, Aalberg V. Psychiatric disorders in orofacial dysaesthesia. Int J Oral Maxillofac Surg 1987;16:402-7.
Brailo V, Vuéiaeeviae-Boras V, Alajbeg IZ, Alajbeg I, Lukenda J, Aeurkoviae M. Oral burning symptoms and burning mouth syndrome-significance of different variables in 150 patients. Med Oral Patol Oral Cir Bucal 2006;11:E252-5.
Gatchel RJ, Garofalo JP, Ellis E, Holt C. Major psychological disorders in acute and chronic TMD: An initial examination. J Am Dent Assoc 1996;127:1365-70, 1372, 1374.
Morris S, Benjamin S, Gray R, Bennett D. Physical, psychiatric and social characteristics of the temporomandibular disorder pain dysfunction syndrome: The relationship of mental disorders to presentation. Br Dent J 1997;182:255-60.
Aditya A, Lele S, Aditya P. Prevalence of symptoms associated with temporomandibular disorders in patients with psychosocial disorders. J Int Dent Med Res 2012;5:26-9.
Winocur E, Hermesh H, Littner D, Shiloh R, Peleg L, Eli I. Signs of bruxism and temporomandibular disorders among psychiatric patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:60-3.
Blasberg B, Greeneberg MS. Orofacial pain. In: Greenberg MS, Glick M, editors. Burket′s Oral Medicine: Diagnosis and Treatment. 10 th
ed. Canada: Elsevier; 2003. p. 317.
Dworkin SF, Burgess JA. Orofacial pain of psychogenic origin: Current concepts and classification. J Am Dent Assoc 1987;115:565-71.
Keene JJ Jr, Galasko GT, Land MF. Antidepressant use in psychiatry and medicine: Importance for dental practice. J Am Dent Assoc 2003;134:71-9.
Katayoun E, Sima F, Naser V, Anahita D. Study of the relationship of psychosocial disorders to bruxism in adolescents. J Indian Soc Pedod Prev Dent 2008;26 Suppl 3:S91-7.
Jensen OE, Featherstone JD, Stege P. Chemical and physical oral findings in a case of anorexia nervosa and bulimia. J Oral Pathol 1987;16:399-402.
Avidan B, Sonnenberg A, Giblovich H, Sontag SJ. Reflux symptoms are associated with psychiatric disease. Aliment Pharmacol Ther 2001;15:1907-12.
Piccoli L, Besharat LK, Cassetta M, Migliau G, Di Carlo S, Pompa G. Tooth wear among patients suffering from mental disorders. Ann Stomatol (Roma) 2014;5:52-60.
Nagabhushna D, Balaji Rao B, Mamatha GP, Rajeshwari A, Raviraj J. Stress related oral disorders - A review. JIAOMR 2004;16:197-200.
Friedlander AH, Marder SR, Pisegna JR, Yagiela JA. Alcohol abuse and dependence: Psychopathology, medical management and dental implications. J Am Dent Assoc 2003;134:731-40.
Morell-Dubois S, Carpentier O, Cottencin O, Queyrel V, Hachulla E, Hatron PY, et al.
Stressful life events and pemphigus. Dermatology 2008;216:104-8.