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RSBO (Online)

versão On-line ISSN 1984-5685

RSBO (Online) vol.12 no.3 Joinville Jul./Set. 2015

 

Case Report Article

 

Oral rehabilitation in a patient with bipolar affective disorder: clinical case report

 

Eduardo RossettiI; Érico Kruchinski de AzevedoI; Bruna Eliza ZaniniI; Vanessa Carriço LemesII; João Armando BrancherII; Maria Fernanda TorresIII; Andréa Paula FregonezeIV

 

I DDS – Curitiba – PR – Brazil
II Positivo Univeristy – Curitiba – PR – Brazil
III Federal University of Paraná – Curitiba – PR – Brazil
IV Pontifical Catholic University of Paraná – Curitiba – PR – Brazil

Correspondence

 

 


ABSTRACT

Objective: This study, through a literature review, aimed to present the key aspects found in Bipolar Affective Disorder (BAD), as well as present a case report of a patient who received dental care in the Discipline of Dentistry for Patients with Special Needs of PUCPR. Case report:Female patient, 30 years of age, leukoderma, diagnosed by medical and psychological exams as suffering from BAD and slight mental retardation. The most evident characteristics inherent to the primary illness included swings in mood and affection as well as bipolar or manic depressions. The special school where she studied and worked referred her to receive dental care in the Discipline of Dentistry for Patients with Special Needs of PUCPR. Her main complaint was the lack of upper front teeth and the esthetic. The treatment plan included adequacy of oral environment through basic periodontal therapy and production of removable partial dentures. Conclusion: People with BAD requires extra care with regard to behavioral management.

Keywords: Dentistry; people with special needs; bipolar affective disorder.


 

Introduction

Bipolar disorder (BAD) is a changing in mood characterized by episodes of extreme excitement and depression, among which there is a latency period 13. It affects between 1% and 2% of the general population, with an equal prevalence between males and females 4. About 50% of patients with BAD report the occurrence of other cases in the family, especially among male monozygotic twins, where the prevalence may reach 80% 2.

BAD can be classified into disorder I, disorder II, dysthymia, cyclothymia, and bipolar disorder without specific cause. In disorder I, one or more manic or mixed episodes occur; in disorder II, one or more depressive episodes accompanied by at least one hypomanic episode occur. Dysthymia is a milder form of chronic depression, which can last up to two years and takes place between 6% and 8% of the adult population. Cyclothymia consists of a brief recurrent episode of hypomania and mild depression, symptoms ranging from depression to manic more quickly than other bipolar patients and cycles are short. Finally, the BAD without specific cause consists of partial syndromes such as recurrent hypomania without depression 12. Although no age range of greater prevalence exists, the greatest onset of disease is between 15 and 24 years of life and if BAD is properly diagnosed and treated, may undergo remission for a period of five years 6.

The main medical findings are chronic fatigue, migraine, asthma, bronchitis, multiple chemical sensitivity, and hypertension. They are also predisposed to obesity, metabolic syndrome, type 2 diabetes, and cardiovascular/cerebrovascular diseases. Of course, these conditions are exacerbated if there is no primary and preventive health care 8.

Although drug therapy is the treatment of choice for patients with BAD, this is not enough by itself because the psychological rehabilitation is necessary; notwithstanding the drugs used have deleterious effects on oral health: marked developing of caries, xerostomia, alterations in taste, and bruxism 13. In particular, the lithium carbonate used in these patients cause hypertrophy of the salivary glands, generalized stomatitis, ulcers on the mucosa, pain and myofascial dysfunction syndrome, xerostomia, and cervical caries lesion 9.

Because treating people with BAD includes a combination of psychoeducation, self-management, pharmacotherapy, and health care, this study aimed to report a case of a patient diagnosed with BAD who received dental care in the Discipline of Dentistry for Patients with Special Needs of PUCPR.

 

Case report

A female patient, 30 years old, leucoderma, diagnosed by medical and psychological tests as having BAD and discrete mental retardation was referred for dental care for by the school where she studied and worked. As the characteristics inherent to her condition were the mood swings, low selfesteem, and manic depressive disorders. Her main complaint was the lack of upper incisors, which, according to her, contributed to her mood changes (figure 1), but reported no pain symptoms.

 

 

 

Past medical history revealed the internment in a psychiatric hospital at the age of 12 for a period of three years and she was diagnosed with mild mental retardation. She used carbamazepine at a dose of 200 mg, for mood stabilization, but reported extreme difficulty to undergo previous dental procedures because of the impatience and the sudden change of mood.

At clinical examination, the patient presented straight profile, lip sealing, and nasal breathing. At intraoral clinical examination, she showed significant loss of teeth (table I) and gingivitis.

 

 

 

The treatment plan includes adequacy of the oral environment through basic periodontal therapy, oral hygiene instruction, endodontic treatment of the tooth 23, followed by restorative phase with multiple restorations, manufacture of metal core and post, provisional crown on a tooth 23, and maxillary and mandibular removable partial dentures (RPD) (figure 2). The patient was followed-up since RPD installation.

 

 

 

Discussion

According to the literature, the prognosis for the BAD is considered relatively favorable, although the results were not so encouraging 7. People with BAD during childhood or early adolescence have a different course of the disease when compared to those developing BAD at adulthood, since adults have more frequent episodes of euphoria and depression 5.

In this study an adult patient, aged 30 years, diagnosed as having bipolar disorder, was treated at the clinic for patients with special needs of the Pontifical Catholic University of Paraná. During the dental treatment, the mood swings, which is characteristic of the disorder 4, was evident throughout the months and contributed to increase her anxiety. It is known that fear and anxiety are relatively common when a person is placed in front of a health professional, however significantly increase when the professional is a dentist 10, so in patients with BAD because of mood swings, extra care is required. The dentist accounts for identifying the factors causing anxiety and fear and implementing different strategies of management behavior by minimizing them 11.

In this case report, behavioral management was important, as she swung between euphoric states and depressive moments. The dental treatment itself was only started after trivial dialogues, which on one hand minimized the discomfort and the initial distrust regarding to the procedures, but on the other hand increased the period of treatment.

Among the most common oral diseases in patients with psychiatric disorders are periodontal disease and caries due to low self-esteem, negativity, and apathy 1. The final result is a significant increase in tooth extractions. In this case report, DMFT index was equal to 24 (D = 2, M = 14, F = 8), number much higher than the mean DMFT of adults aged 35 years living in southern Brazil 3.

Thus, the established treatment plan aimed at the adequacy of oral cavity with hygiene instructions, periodontal prophylaxis, and restorations, returning oral health. This was followed by endodontic treatment of the upper left canine tooth, which went smoothly, although with some episodes of further unrest by the patient.

At the final stage of restorative treatment, she opted by maxillary and mandibular RPD due to the difficulty of maintaining oral hygiene. RPD eliminates the need for additional niches, which further contribute to the accumulation of food residue. At the subsequent appointments, there was a distinct improvement in mood and selfesteem of the patient, important aspects from the psychotherapeutic point of view 6. The patient was followed-up at every four months to monitor oral health.

 

Conclusion

The treatment of people with BAD requires extra care regarding to the behavioral management. Longer appointments are needed to establish a greater connection between the dentist and the patient. Strategies should be developed to motivate the patient constantly.

 

References

1. Almomani F, Brown C, Williams KB. The effect of an oral health promotion program for people with psychiatric disabilities. Psychiatr Rehabil J. 2006;29(4):274-81.         [ Links ]

2. Belmaker RH. Medical progress bipolar disorder. N Engl J Med. 2004;351(5):476-86.

3. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Projeto SB Brasil 2010. Resultados principais. Brasília: MS/Coordenação Nacional de Saúde Bucal. 51 p. [cited 2015 Mar 10]. Available from: URL:http://dab.saude.gov.br/CNSB/sbbrasil/ arquivos/projeto_sb2010_relatorio_final.pdf.

4. Clark DB. Dental care for the patient with bipolar disorder. J Can Dent Assoc. 2003;69(1):20-4.

5. Findling RL, Gracious BL, McNamara NK, Youngstrom EA, Demeter CA, Branicky LA et al. Rapid, continuous cycling and psychiatric comorbidity in pediatric bipolar I disorder. Bipolar Disord. 2001;3(4):202-10.

6. Friedlander AH, Friedlander IK, Marder SR. Bipolar I disorder psychopathology, medical management and dental implications. J Am Dent Assoc. 2002;133(9):1209-17.

7. Huxley N, Baldessarini RJ. Disability and its treatment in bipolar disorder patients. Bipolar Disord. 2007;9(1-2):183-96.

8. McIntyre RS, Konarski JZ, Soczynska JK, Wilkins K, Panjwani G, Bouffard B et al. Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization. Psychiatr Serv. 2006;57(8):1140-4.

9. Nápole RCO, Cillo J, Haddad AS. Transtornos psiquiátricos em Odontologia. In: Haddad AS. Odontologia para pacientes com necessidades especiais. São Paulo: Santos; 2007. p. 241-61.

10. Nathan JE. Behavioral management strategies for young pediatric dental patients with disabilities. Journal of Dentistry for Children. 2001;68(2): 89-101.

11. Possobon RF, Carrascoza KC, Moraes ABA, Costa AL. O tratamento odontológico como gerador de ansiedade. Psicologia em Estudo. 2007;12(3):609-16.

12. Rosmus L, Cobban SJ. Bipolar affective disorder and the dental Hygienist. JCHD. 2007;41(2): 72-83.

13. Schulte PFJ, Brand HS. Bipolaire Stoornissen em mondgezondheid. Ned Tijdschr Tandheelkd. 2010;117(1):493-9.

 

 

Corresponding author:
Andréa Paula Fregoneze
Avenida Manoel Ribas, 750, apto 303
CEP 8051-020 – Curitiba – PR – Brasil
E-mail: afregoneze@gmail.com

 

Received for publication: June 19, 2015
Accepted for publication: July 21, 2015