|Year : 2014 | Volume
| Issue : 2 | Page : 43-48
Oral health and treatment needs of patients with psychosocial disorders in Pune, India: A cross-sectional study
Amita Aditya1, Shailesh Lele1, Priyam Aditya2
1 Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, Pune, India
2 Aditya's Dental Privilege, Pune, Maharashtra, India
|Date of Web Publication||21-Oct-2014|
Department of Oral Medicine and Radiology, Sinhgad Dental College and Hospital, S. no. 44/1, Vadgaon (Bk), Off Sinhgad Road, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Despite of the fact that good oral health is essential to maintain a good overall health and quality of life; it generally gets low priority in patients with psychosocial disorders. Very little data are available to estimate the current oral health status of patients with psychosocial disorders and their treatment needs. Hence this study was conducted to determine the oral health status and treatment needs of patients in Pune, India. Materials and Methods: Two hundred patients who were above 18 years of age; diagnosed with psychosocial disorders, and either institutionalized or under out-patient care in three rehabilitation centers of Pune participated in this study. To determine their caries experience; decay-missing-filled teeth (DMFT) index was used where as screening of periodontal problems was done using Basic Periodontal Examination (BPE) index. Presence of any oral mucosal lesion was also recorded. Results: Mean DMFT score for all 200 participants of this study was 5.52. Among the particular psychosocial diagnosis groups, mean DMFT was relatively higher in schizophrenic (6.71) and depressive patients (5.82). BPE index showed considerable periodontal treatment needs. Mucosal lesions associated with tissue abuse habits were present in 24 (12.0%) participants, with a majority of them occurring in patients with alcohol withdrawal syndrome, schizophrenia and depression. Three (1.5%) patients were found to have self inflicted mucosal lesions where as 9 (4.5%) patients had other mucosal lesions viz. lichen planus, glossitis etc. Conclusion: Although the caries experience of the participants of this study was not on the higher side, large unmet dental treatment need was identified in this population. Awareness as well as practice of oral hygiene methods was also poor. This calls for integrated efforts on the behalf of psychiatrists, care takers and dentists towards providing a better oral health care to this often neglected group of patients.
Keywords: DMFT index, oral health status, psychosocial disorders
|How to cite this article:|
Aditya A, Lele S, Aditya P. Oral health and treatment needs of patients with psychosocial disorders in Pune, India: A cross-sectional study. Dent Med Res 2014;2:43-8
|How to cite this URL:|
Aditya A, Lele S, Aditya P. Oral health and treatment needs of patients with psychosocial disorders in Pune, India: A cross-sectional study. Dent Med Res [serial online] 2014 [cited 2020 Jul 14];2:43-8. Available from: http://www.dmrjournal.org/text.asp?2014/2/2/43/143331
| Introduction|| |
A psychosocial disorder is a mental illness caused or influenced by life experiences, as well as maladjusted cognitive and behavioral processes.  It affects people of all nations and of socio-economic strata. Varying prevalence reports of psychiatric disorders have been reported in India, ranging from 9.5-370 per 1000 population. 
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.  Hede (1995) and certain other authors have reported that physical health problems in psychiatric patients are poorly recognized by the psychiatrists and oral health is no exception. ,,
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. 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. ,,
Despite of these reports, very little data are available about the oral health and treatment need of patients suffering from psychosocial disorders in India. Hence, this study was done with an aim to assess the oral health status and treatment needs in a group of institutionalized and non-institutionalized patients with psychosocial disorders. To the best of the authors' knowledge, this is the only such study done in this geographical region.
| Materials and Methods|| |
Patients diagnosed with psychosocial disorders and under treatment in three different rehabilitation centers of Pune were approached to participate in this study. These patients were either admitted in the center or were under out-patient care. The investigators conducted this study at these centers after obtaining due permissions from the concerned authorities. Some patients who reported to the out-patient Department (OPD) of Bharti Vidyapeeth Dental College and Hospital, Pune and had a history of psychosocial disorders were also included in the study. Adults over the age of 18 years, who were medically stable that is, not under psychotic attack and were capable of understanding the supplied information and provide informed consent were considered for the study, and were explained the need and the procedure of the study. Out of the total 218 potential participants, 200 agreed for the participation, and signed the informed consent to become participants of the study. Ethical clearance for the study was taken from the institutional ethical committee and research review board.
The participant's demographic data, details of their psychosocial disorder as well as the management and stage of recovery were retrieved from their most recent records and entered in a pre-designed proforma [Annexure 1] [Additional file 1]. Their relevant dental and personal habit history (including tissue abuse habit) was also recorded and entered in the proforma.
In the presence of a hand-held source of illumination, oral examination was performed systematically using suitable clinical armamentarium.
Decayed-missing-filled teeth (DMFT) index was used to estimate the dental status of the participants.  Examination of the teeth for the same was conducted using a no. 3 plain mouth mirror and no. 23 explorer (sickle probe or pig tail explorer).
DMFT index is an irreversible index, meaning that it measures total lifetime caries experience. It is applied only to permanent teeth and is composed of three components, the D-component for "decayed", M-component for "missing" and the F-component for "filled".
All the permanent teeth of the participants were examined. The teeth not included were:
- The third molars
- Congenitally missing and supernumerary teeth
- Teeth removed for reasons other than dental caries, such for orthodontic treatment or impaction
- Teeth restored for reasons other than dental caries, such as trauma or for use as a bridge abutment
- Retained primary teeth.
For assessment of periodontal health of the participants, Basic Periodontal Examination (BPE) was done using the World Health Organization (WHO) probe. Although BPE does not provide a diagnosis, it is a simple and rapid screening tool that may be used to indicate the periodontal status and provide basic guidance on treatment need. 
Examination of oral mucous membrane was also carried out with the help of two no. 3 plain mirrors and digital palpation as and when required. Presence of any oral lesion; including lesions associated with tissue abuse habit or self-inflicted injury was recorded.
The data thus collected was analyzed using descriptive analysis. The results were also compared post-hoc to a parallel study conducted in the Department of Oral Medicine and Radiology, Bharti Vidyapeeth Dental College and Hospital, Pune for analyzing oral symptoms in general population.
| Results and Discussion|| |
Two hundred patients participated in this study out of which 125 were males with a mean age of 35.81 (SD ± 14.1) and 75 females with a mean age of 38.65 (SD ± 12.8). Majority of the participants (62.5%) were men. However, this does not directly indicate that the psychosocial disorders are more prevalent in males, as the study population consisted of individuals seeking psychosocial therapy at one of the centres rather than from the general population. This gender discrepancy could probably be attributed to the supposition that men seek treatment for their psychosocial disorder more often than females. It may also be attributed to the stigma and fear of discrimination associated with the mental health problems which might prevent people, women in particular, from disclosure of their condition and seeking professional treatment. A report published by WHO in 2005 indicates that although overall there is little difference in prevalence of mental disorders in males and females, there are marked male:female differentials in the prevalence of specific disorders. Both depression and eating disorders exhibit a marked female excess, where as substance abuse disorders are more marked in males. It was also indicated in the report that gender has profound implications on many aspects of mental health disorders and the burden of care and associated stigma are greater for females.  A survey of an urban community in southern India found that one-third of people with schizophrenia had never accessed any treatment resources. 
Majority of participants (53.5%) belonged to the age group of 18-35 years. Also, as the age advanced the number of participants with psychosocial disorder decreased, and this pattern was even more remarkable in men. As per our experience during the study, this age-distribution could be secondary to a changing life style pattern and competitiveness especially in the urban youth and rising levels of stress. This was similar to a study done by Kumar M et al., in which psychiatric disorders were more prevalent in the age-group of 15-24 years. 
These patients were either institutionalized (90.5%), or were being managed on out-patient basis (9.5%). As far as the distribution of psychosocial disorders is concerned, schizophrenia was the commonest psychosocial disorder seen in 83 (41.5%) patients; followed by depression (13%), bipolar disorder (8.5%) and alcohol withdrawal syndrome with psychosis (7.5%). Depression and bipolar mood disorder, if taken together, formed the second largest group of disorders (27.5%).
As far as gender-wise distribution is concerned, all the psychosocial disorders were more prevalent in men in this study group, except for depression; which was significantly high (P value = 0.004, relative risk = 1.77) in women.
In the present study, caries experience (caries prevalence and associated morbidity) was estimated with the help of DMFT index. Dental caries is a multifactorial disease. Salivary flow and oral hygiene status are among the important factors associated with the incidence of caries. Low self-care and poor hygiene maintenance have been reported in patients with psychosocial disorders.  Various investigators have also reported poor oral hygiene status in such patients. ,,, Also, both psychosocial disorders and psychotherapeutic drugs have been associated with decreased salivary flow. In view of these findings, one would expect high caries incidence in these patients. In a meta-analysis done by Kisely S et al., People with severe mental illness had 3.4 times the odds of having lost all their teeth than the general community. 
[Table 1] depicts the mean DMFT scores in participants with those psychosocial disorders which are particularly associated with low self-care and decreased functional abilities, viz. schizophrenia, depression, bipolar mood disorder, polysubstance abuse disorder and schizoaffective disorder. Mean DMFT scores ranged from 3.35 in bipolar mood disorder, through 5.82 in depression to 6.71 in schizophrenia.
The relatively higher mean DMFT scores in patients with schizophrenia and depression could be explained more on the basis of general slowing down of activities and apathy towards personal and oral hygiene, than on the basis of physical disability to maintain oral hygiene.
It would be interesting to compare these DMFT scores with those in the general population of similar age range. Considering the fact that the DMFT score can range from 0-28, the caries experience could be categorized as low if the DMFT score ranges between 0-9, moderate if it ranges from 10-18, and high if it ranges from 19-28. In a parallel study done in Department of Oral medicine and Radiology, Bharti Vidyapeeth Dental College and Hospital, Pune for analyzing oral symptoms in general population, the DMFT score was found to be 4.58 in the age group of 36 years and above. The mean DMFT score of the psychiatric patients of the same age range in our study (36 and above) was 7.24. Though the DMFT score in the latter group is more than in the general population, if we consider the above categories, both fall in the low caries experience group. Even the mean DMFT scores of 6.71 and 5.82 respectively in schizophrenic and depressive individuals are not much different from that in general population. Since the demography of the population studied in these two studies is similar, it appears that the presence of psychosocial disorders does not significantly affect the dental caries and associated morbidity.
In a study of general population that was carried out in another geographic location in India, mean DMFT score of 9.75 was obtained in individuals 35 years and above. 
According to a report published by National Commission on Macroeconomics and Health, Government of India in 2005, the mean DMFT score estimated by various studies in the age group of 30 years and above, ranged from 0.40-3.80. Based on the analysis of all these studies, the mean DMFT score in age group 30-35 years was calculated to be 1.39. Mean DMFT in age group 60 and above was found to be 13.51. 
Mean DMFT score for all 200 participants of our study was 5.52. Among the particular psychosocial diagnosis groups, mean DMFT was relatively higher in schizophrenic and depressive patients. In a study done in Istanbul, Turkey also; DMFT was found to be significantly higher in the schizophrenic patients.  On the other hand, the DMFT score did not increase significantly with age in our study population.
For assessment of periodontal health of the participants, BPE was used as the screening tool. Twenty three percent (46) the participants were found to have a BPE score of 4, 54% (108) of 3 whereas 12% (24) participants had the score of 2. Only 9% (18) participants were found have the score of 1. The BPE scores increased significantly with age (P value = 0.003). Poor periodontal status may be contributed to low awareness of oral hygiene practices among these patients. As many as 29 (14.5%) of the participants reported that they did not clean their teeth regularly. This definitely indicates a significant need to increase oral hygiene awareness and provision of periodontal treatment and care in patients with psychosocial disorders.
As far as oral mucosal lesions were concerned, lesions associated with tissue abuse habits were present in 24 (12.0%) participants, with a majority of them occurring in patients with alcohol withdrawal syndrome, schizophrenia and depression. Of these 24 participants, 17 had leukoplakia, 6 had oral submucous fibrosis (OSMF) and 1 had both leukoplakia and OSMF. Except for one, all the lesions were found in male participants. The presence of lesions appeared to be unrelated to the nature of the psychosocial disorder, and is related to the tobacco habit, which is known to be more prevalent in males. Self-inflicted injuries to oral mucosa were seen in three (1.5%) participants. Besides these lesions, nine participants exhibited some other lesions, viz. glossitis, mucosal pallor, oral lichen planus, candidiasis and aphthous ulcer. No significant correlation could be established between the presence of these lesions and other variables used in this study such as age, duration of psychosocial history etc.
Our study had certain limitations. We could have used a larger sample size and more comprehensive indices for assessing the oral health status of the patients, especially their periodontal health. However, considering generalized apprehensions prevalent in this group of patients and other patient management issues, we used simpler screening methods.
| Conclusions|| |
The findings of this study indicate a poor status of oral health along with extensive dental treatment needs amongst the patients with psychosocial disorders in the Pune region. With an exception of specific disease groups like schizophrenia, though the mean DMFT score of this population falls in low caries group; the need of dental care for patients with psychosocial disorders is certainly more as compared to the general population. The poor oral hygiene and compromised periodontal status also indicate unmet treatment needs. It is thus a need of the hour that the psychiatrists, social workers, caretakers and dentists co-ordinate their efforts in ensuring provision of a better oral health for this often neglected group of patients.
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