Bipolar affective disorder and the dental hygienist.

ABSTRACT

Bipolar affective disorder (BD) is a chronic and often debilitating condition affecting 1% to 2% of the general population. Although BD affects a small population, it is likely that a dental hygienist will encounter individuals suffering from BD sometime during his or her practice. This article describes BD, the drugs used to treat it, dental hygiene implications for the client with BD, and discusses treatment of the client with bipolar disorder within the Oral Health-Related Quality of Life framework. The major features of BD consist of mood disturbances: depression, hypomania, and mania. The precise etiology of BD is unknown. Pharmacotherapy forms the foundation for management of BD and involves administration of mood stabilizers, antidepressants, sedatives, antiepileptics, and antipsychotics. A dental hygienist may expect a client with BD to present with several oral health conditions: xerostomia induced by medication, abrasion of teeth from excessive brushing during mania, gingival injury due to excessive/overeager flossing during mania, inadequate nutrition, or poor oral hygiene due to neglect during depression. The client may be concerned with the daily living aspects associated with bipolar disorder, may not feel that oral health needs are a priority, or may not have the resources to fill those needs. It is important for dental hygienists to acknowledge this difference in perspective in viewing the importance of oral health care. The Oral Health-Related Quality of Life model (OHRQL) provides a framework for aiding the dental hygienist in determining the optimum therapeutic regimen for oral health care for the BD client.

Keywords: bipolar disorder; dental hygienists; oral health; oral hygiene; Oral Health-Related Quality of Life model

RESUME

Le trouble affectif bipolaire est un trouble chronique et souvent debilitant qui affecte un a deux pourcent de la population en general. Bien que le trouble bipolaire n'affecte qu'une petite partie de la population, une hygieniste dentaire rencontrera probablement quelques fois des personnes souffrant de trouble bipolaire au cours de ses annees d'exercice. Cet article decrit le trouble bipolaire, les medicaments utilises pour le traiter, les repercussions sur l'hygiene dentaire d'un client atteint de trouble bipolaire et ouvre la discussion concernant le traitement d'un client atteint de trouble bipolaire dans le cadre de la qualite de vie liee a la sante buccodentaire. Les principales caracteristiques du trouble bipolaire sont des troubles de l'humeur: depression, hypomanie et manie. L'etiologie precise du trouble bipolaire est inconnue. La pharmacotherapie est la base de la gestion du trouble bipolaire et elle inclut l'administration de stabilisateurs de l'humeur, antidepresseurs, sedatifs, antiepileptiques et antipsychotiques. Une hygieniste dentaire peut s'attendre a ce qu'un client atteint de trouble bipolaire presente plusieurs affections buccodentaires: xerostomie causee par les medicaments, abrasion des dents causee par le brossage excessif en phase maniaque, blessures gingivales dues a une utilisation excessive de la soie dentaire en phase maniaque, ou mauvaise hygiene dentaire due a la negligence en phase depressive. Le client peut etre preoccupe par les aspects de la vie quotidienne associes au trouble bipolaire et peut ne pas avoir le sentiment que les besoins en matiere de sante buccodentaire sont une priorite ou peut ne pas avoir les ressources pour repondre a ces besoins. Il est important que les hygienistes dentaires reconnaissent cette difference de perspective sur l'importance des soins de sante buccodentaire. Le modele de qualite de vie liee a la sante buccodentaire (OHRQL) offre un cadre pour aider l'hygieniste dentaire a determiner le plan therapeutique optimal pour les soins de sante buccodentaire d'un client atteint de trouble bipolaire.

BIPOLAR AFFECTIVE DISORDER AND THE DENTAL HYGIENIST

BIPOLAR AFFECTIVE DISORDER (BD) IS A CYCLIC MENTAL illness and includes a spectrum of disorders. BD was previously referred to as bipolar disorder and as manic-depressive insanity, manic-depressive disorder, and manic depression. BD is a chronic and often debilitating condition affecting 1% to 2% of the general population. (1) The onset of BD generally occurs in the late teens or early twenties.

The societal cost of BD is high: absences from work cost employers 50% to 150% more than health-related absences for individuals without BD; (2) health care costs have been estimated to range from $25 billion to $45.2 billion annually. (3) Sufferers are twice as likely to be incarcerated (4) and are at a 15 to 20 times greater risk for suicide than the general population. (5) Individuals with BD are also more likely than the general population or those with unipolar depression to experience substance abuse. Studies have found that 43.7% of sufferers of BD exhibit some form of alcohol dependence or abuse compared with 16.6% of those with unipolar depression, and 14% of the general population. The high incidence of co-morbid BD and substance abuse poses a challenge for treatment and management for each separate condition. For instance, concomitant alcohol dependence or abuse results in increased hospitalizations, more mixed mania, earlier age of onset, and an increase in suicidal ideation. (6)

Although BD affects a relatively small population, it is likely that a dental hygienist will encounter individuals suffering from BD sometime during his or her practice. Few reviews or studies have been conducted on the topic of BD and oral health, and the purpose of this article is to inform dental hygienists about BD and its oral effects. This article describes BD, the drugs used to treat BD, dental hygiene implications for the client with BD, and discusses treatment of the client with bipolar disorder within the Oral Health-Related Quality of Life framework.

FEATURES OF BIPOLAR DISORDER

The major features of BD consist of mood disturbances: depression, hypomania, and mania. Depressive episodes occur three times more often than manic episodes, lead to eight times more hospitalizations, (3) and include at least three of the following: intense, pervasive feelings of sadness for most of the day; an inability to concentrate; a decrease in interest or pleasure in activities previously found interesting; marked gain or loss in weight; sleep disturbances; persistent thoughts of death; suicidal ideation with or without a specific plan, or suicide attempt; psychomotor agitation or retardation; feelings of worthlessness or inappropriate guilt; and fatigue. (3-9) Major depressive episodes can last from two weeks to nine months. (1,3,8,9) Mania consists of three of the following: feelings of elevated; expansive mood; irritability; loss of self control and judgment; psychotic thinking and behaviour; grandiosity; increased sexuality; appetite disturbance; racing thoughts; creative or bizarre thinking; risk taking; decreased need for sleep; pressured speech; and increased or delusional religious thoughts or experiences. (1,4-9) Excessive goal-striving behaviours or intense mood reactivity to success and reward have also been noted as risky attitudes for bipolar disorder mania. (10-12) Sometimes individuals with BD find themselves in a state of euthymia that represents premorbid levels of mood. (13)

Hypomania is a condition composed of increased productivity and a decreased need for sleep. Hypomania is often not seen as pathologic by the sufferer because it is a condition marked by high functionality. However, it is dangerous as it is accompanied by a high risk for suicidal behaviour and social impairment and can be followed by manic episodes. (1,4-9) Mixed episodes consist of a combination of concurrent depressive and manic symptoms. (1,4-9) There are five different disorders included in the spectrum of bipolar affective disorders: Bipolar I, Bipolar II, dysthmia, cyclothmia, and Bipolar disorder NOS. (1-9) The most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) indicates a diagnosis of Bipolar I is possible with the occurrence of one or more manic or mixed episodes; and Bipolar II with the occurrence of one or more major depressive episodes, accompanied by at least one hypomanic episode. (5) Dysthmia is a milder, chronic form of depression, which can last for two years and occurs in 6% to 8% of the adult population. (1,5,8,9) Dysthmia symptoms have also been referred to as subsyndromal bipolar disorder. (5,12,13) Cyclothymic disorder consists of recurrent brief episodes of hypomania and mild depression. Individuals suffering from cyclothmia are often called "rapid-cyclers" because their symptoms vary from depression to mania much more rapidly than other BD sufferers, with cycles as short as two months. (1,4,5) Bipolar disorder NOS consists of partial syndromes, such as recurrent hypomania without depression. (1,4,5)

Bipolar affective disorder can occur simultaneously with substance abuse, anxiety, and personality disorders. Evidence exists for a link between BD and eating disorders, particularly between Bipolar II and bulimia nervosa. (14) BD can also be induced or mimicked by substance abuse, medications, or other psychiatric illnesses involving psychosis. (4,12,13) It has been noted that in some cases substance abuse problems can mask underlying mood disturbances, and that treatment of the latent BD can improve recovery from substance abuse. (15) Genotypes have been discovered that may indicate an overlap between bipolar disorder with persecutory delusions and schizophrenia. (16) It is because of these associations, and the fact that individuals do not generally see hypomania as pathologic, (4,10,13) that BD is often initially misdiagnosed as major depressive disorder or one of the above conditions. Some studies approximate the average latency of bipolar disorder before diagnosis as 8.3 years. (13) This delay in diagnosis can lead to a poorer prognosis, increased complications (such as substance abuse), increased risk of suicide, and impaired quality of life.

The precise etiology of BD is unknown; however, several theories exist. Studies have shown abnormalities in the prefrontal cortex, limbic, striatum, ventricular volume, and in the serotonin, hypothalamic-pituitary-thyroid, and adrenal systems. (12,13) Family studies indicate a strong genetic component to the disorder. (4,7-10,12,15) Some evidence suggests that abnormalities of chromosome 22 may predispose an individual to bipolar disorder. (15) Some theorists view bipolar disorder in an evolutionary framework, as some of the features may attend for propagation of the species, i.e., depression may make individuals less sensitive to the suffering of others, and an anxious temperament may help to ensure the survival of self and kin. (17)

The four general approaches for treatment include pharmacotherapy, psychotherapy, peer support/life skills education, and electro-convulsive therapy (electroshock therapy, or ECT). It is advocated to include all of the above treatments, with the exception of ECT, in effective BD treatment. (1,5,8) While pharmacotherapy is the major form of intervention, stressors and major life events have been shown to exacerbate BD or cause relapse in cases of remission and therefore peer support and life skills management to foster coping skills are important parts of therapy. (4,18,19) The addition of psychotherapy to pharmacotherapy has shown to improve prognosis and increase length of remission in bipolar disorder patients. (4,7,9,11,18-21) Patients being mindful of their illness, having a stay-well plan, and including intervention strategies and coping skills for episodes of illness can improve the course of treatment. (22) ECT is recommended only in refractory situations not improved by pharmacotherapy and psychotherapy. (1,5,8)

PHARMACOTHERAPY

Pharmacotherapy forms the foundation for management of BD and involves administration of mood stabilizers, antidepressants, sedatives, antiepileptics, and/or antipsychotics to help alleviate the effects of depression, hypomania, and mania and to prevent mood disturbances in stages of remission. There are some discrepancies among the appropriate first-line drugs used to treat BD. According to the Canadian Network for Mood and Anxiety Treatments (CANMAT), the first line of treatment for acute mania includes administration of the mood stabilizers lithium and valproate and atypical antipsychotics. (5) The first line of treatment for depression is lithium, lamotrigine, and various combinations of antidepressants and mood stabilizers. For bipolar depression, the American Psychiatric Association guidelines indicate lithium or lamotrigine as the first line for treatment. (23) The World Federation of Societies for Biological Psychiatry advocates the administration of an antidepressant and mood stabilizer as the first line treatment for bipolar depression. (21) For maintenance, use of lithium, lamotrigine, valproate and olanzapine is advocated. (5) There are varying side effects for the various drugs used to treat BD; however, weight gain is seen with all drugs except lamotrigine and carbamazepine. (1,4,18) The next section of this paper will review some of the more common drugs considered by CANMAT to be first-line treatments for BD.

Mood Stabilizers

Lithium. Lithium is a mood stabilizer generally given in the form of a chloride salt. The mechanism of the anti-manic and antidepressant action in the central nervous system (CNS) is unknown; however, it may interfere with the synthesis, storage, and release of monoamine neurotransmitters norepinephrine and dopamine. (24-26) Lithium enhances the uptake of tryptophan, increases the synthesis of serotonin, and may enhance the release of serotonin in the CNS. The lithium ion competes at intracellular binding sites, protein surfaces, and transport sites with sodium, potassium, calcium, and magnesium ions. (24) Lithium exerts neurotrophic effects on the brain and has been found to enhance dendritic branching, the development of new synapses, and neurogenesis. (26) Compared with other mood stabilizers, lithium has shown the greatest efficacy in the prevention of suicide.

When taken with erythromyocin, NSAIDs, diuretics, ACE inhibitors, and calcium channel blockers, there is an increase in serum lithium levels that can lead to toxicity. Major side effects of lithium use include weight gain, lethargy, fatigue, impaired glomeruluar or tubular functioning, tremor, cognitive impairment, hypothyroidism, nausea, vomiting, diarrhea, dry mouth, benign leukocytosis, acne, psoriasis, and electrocardiogram changes. (1,24) After 10 years of therapy with lithium, 10% to 20% of patients display kidney changes such as interstitial fibrosis, tubular atrophy, and glomerular sclerosis. Because of the side effects of lithium, adherence to lithium therapy is poor and many patients discontinue lithium treatment. Therefore, several therapies may be tried in order to find the right treatment for the right individual that may or may not include lithium pharmacotherapy.

Atypical Antipsychotics

Quetiapine. Quetiapine is administered in monotherapy or in combination with lithium or valproate. When administered alone, quetiapine has been shown to be effective in reducing depressive as well as manic symptoms. (5,7,27) Quetiapine is a dibenzothiazepine derivative, an antagonist at Serotonin 5-H[T.sub.1A] and 5-H[T.sub.2A] Dopamine [D.sub.1] and [D.sub.2] histamine [H.sub.1] and Adrenergic [[alpha].sub.1] and [[alpha].sub.2] receptors. (7) The mechanism for action of quetiapine in bipolar disorder is unknown.

The side effects of quetiapine are as follows: somnolence, dry mouth, dizziness, weight gain, constipation, and sedation. In combination with lithium or valproate, somnolence, dry mouth, asthenia, and postural hypotension occurred more often than for placebo plus lithium or valproate. For adolescents in combination therapy, sedation was the only side effect seen more often with quetiapine. (27)

Resperidone. Resperidone is an atypical antipsychotic that has been shown to be effective in the treatment of bipolar mania. (1,5,18,25) Resperidone is a benzisoxazole derivative and antagonizes serotonin and dopamine. (27) Resperidone has a high affinity for serotonin 5-H[T.sub.2A], dopamine [D.sub.2] and adrenergic [[alpha].sub.1] and [[alpha].sub.2] receptors. The precise mechanism of resperidone is unknown. Resperidone is given in monotherapy or in combination therapy with mood stabilizers.

Side effects of resperidone include weight gain, extrapyramidal symptoms, somnolence, hyperkinesias, headache, dizziness, dyspepsia, nausea, and constipation. Increased prolactin levels, and hyperprolactinemia can also result from resperidone use. (12,18) In children and adolescents, sialorrhea has also been noted as a side effect with the use of resperidone. (27)

Olanzapine. Olanzapine is a thienobenzodiazepine neuroleptic. The mechanism of action for olanzapine is unknown. However, it is thought to work by antagonizing dopamine and serotonin activities and selectively antagonizing monoamines with high affinity binding to serotonin 5-H[T.sub.2A] and 5-H[T.sub.2C], dopamine [D.sub.1-4], muscarinic [M.sub.1-5], histamine [H.sub.1] and [[alpha].sub.1] adrenergic receptor sites. (12) Olanzapine has been shown effective for the treatment of bipolar mania and for maintenance therapy when taken in monotherapy or combination with fluoxetine. (5,23)

Side effects of olanzapine include headache, somnolence, insomnia, agitation, nervousness, hostility, dizziness, dystonic reactions, parkinsonian events, xerostomia, constipation, premenstrual syndrome, rhinitis, cough, and weight gain. (18,28)

Antiepileptic Drugs

Lamotrigine. Lamotrigine is a second-generation antiepileptic phenyltriazine derivative. Lamotrigine is one of the most studied of the antiepileptic drugs for treatment of BD, (1,4,9,18,20-23,25,28,29) particularly for maintenance therapy, cyclothymia (rapid cycling), and bipolar depression. (14,29,30,31) The precise mechanism of antiepileptic drugs in the treatment of bipolar disorder is unknown; however, the primary action of lamotrigine and other antiepileptics used to treat mood disorders appears to be blockage of gated sodium channels. (26,29-33) This action may inhibit GABA firing. Lamotrigine also modulates serotonergic transmission and affects potassium channels.

Lamotrigine may reduce the efficacy of oral contraceptives, and concurrent use of valproate may inhibit the efficacy of lamotrigine. Side effects of lamotrigine include headache, dizziness, ataxia, somnolence, nausea, diplopia, blurred vision, dermatologic rash, altered taste sensation, and rhinitis. (28-33)

Carbamazepine. Carbamazepine is an anticonvulsant chemically related to tricyclic antidepressants that limits influx of sodium ions across cell membranes. It has anticholinergic, antineuralgic, antidiuretic, muscle relaxant, antiarrhythmic, and anticonvulsant effects. (28) Carbamazepine has been used since the 1980s and has shown to be particularly effective when used in combination with lithium to treat bipolar disorder. (17,19,24,32) Carbamazepine is also prescribed as an alternative to lithium for those who do not respond to lithium, for whom the side effects of lithium are too debilitating, or in the case of mood-incongruent delusions. (28) Side effects of carbamazepine are the same as the side effects of lamotrigine. Erythromyocin, ketoconazole, and clarithromycin may increase serum levels of carbamazepine and lead to toxicity. Phenobarbital, phenytoin, rifampine, and theophylline may decrease serum levels and lead to symptoms of mania. (5)

Valproate. Valproate is also known as valproic acid, or divalproex. Valproate increases availability of GABA at postsynaptic receptor sites, thereby increasing inhibitory effects. Valproate is used particularly to treat bipolar mania in combination with atypical antipsychotics or antiepileptics. (5,18,19,22,25,28) Valproate is prescribed as an alternative to lithium and has been shown to be as effective in treatment of bipolar disorder as lithium or carbamazepine. (5,11)

Side effects reported include somnolence, dizziness, nervousness, insomnia, alopecia, nausea, diarrhea, vomiting, abdominal pain, dyspepsia, thrombocytopenia, tremor, weakness, and respiratory tract infection. (26,32) Otitis media has also been noted as an adverse effect of valproate. (8)

Antidepressants

Fluoxetine. Fluoxetine, also known as Prozac, is a selective serotonin re-uptake inhibitor (SSRI) that prevents presynaptic neurons from re-uptaking released serotonin from the synapse. This action effectively increases the serotonin available to the postsynaptic neuron. Side effects of SSRI use include SSRI-induced bruxism, xerostomia, headache, anxiety, nervousness, somnolence, nausea, weakness, tremors, diarrhea, rash, pruritus, and pharyngitis. (27) Fluoxetine in combination with olanzapine has shown to be effective in the treatment of bipolar depression and for maintenance therapy. (26,31)

IMPLICATIONS FOR THE DENTAL HYGIENIST

Bipolar disorder is a cyclic illness that has oral effects. A dental hygienist may expect a client with BD to present with several oral health conditions: xerostomia induced by medication, abrasion of teeth from excessive brushing during mania, gingival injury due to excessive or overeager flossing during mania, poor oral hygiene due to neglect during depression. (1,8,34) Inadequate nutrition intake due to a client's inability to maintain sufficient nutrient intake during manic or depressive episodes, as well as the prevalence of cigarette smoking and alcoholism can have oral effects. (35,36,37) The client in a depressive or manic state may be unable to shop or purchase groceries, or prepare nutritious meals. Poor/inadequate nutrition due to co-morbid alcoholism could lead to a deficiency in vitamins. Alcoholism predisposes an individual to deficiencies in the B vitamins, zinc, magnesium, and copper, leaving the oral cavity more susceptible to infection and tissue breakdown. Cigarette smoking can lead to deficiencies in vitamin C, a key vitamin in the regeneration of gingival tissue and in the immune response to bacterial challenge. (35) The dental hygienist can advise clients as to an adequate intake of fruits and vegetables or advise them to use a multivitamin supplement if they are unable to follow Canada' Guidelines for Healthy Eating for a period of time. Consultation with the client's physician or a dietician may be indicated for certain clients with BD, depending on their capacity to maintain adequate nutrient intake and confounding factors such as co-morbid alcoholism or cigarette smoking.

Alcohol and tobacco use, both separately but particularly contemporaneously, increases a client's risk for developing head and neck cancer. (36) Because clients with bipolar disorder are more likely to have alcohol use disorders and use tobacco, (6,37) it is likely that a client presenting with BD will be in this high-risk group. In order to facilitate early intervention, the dental hygienist should perform thorough head and neck examinations at each appointment and monitor any changes in tissue, referring clients with signs suspicious of oral cancer to a specialist. A study indicates that alcohol-addicted persons, with or without concurrent smoking, have a high risk for periodontal breakdown and tooth loss, and frequent vomiting associated with alcoholism is associated with erosion of the tooth structure. (38)

Oral health education about the risks of over-brushing and over-flossing should be implemented in order to prevent further damage. During episodes of depression, oral hygiene neglect is common, as is decreased salivary gland output, a preference for carbohydrates, and a high Lactobacillus count. (1,39-41) These factors place individuals suffering with bipolar depression at a very high risk for rampant decay, and intervention with fluoride application in-office and a fluoride rinse for at-home use is recommended.

Extrapyramidal effects resulting from atypical antipsy-chotics, particularly resperidone, often have an orofacial component: acute dystonia creating mastication muscle spasms, pseudoparkinsonianism resulting in a mask-like face and drooling, and tardive dyskinesia manifesting as lip smacking and tongue protrusion. (8,31) Use of a bite-block and low-volume suction during treatment may be necessary in these cases. Oral health aids, such as thick-handled toothbrushes and two-headed toothbrushes, to help a client with symptoms of tremor may be necessary. SSRI-induced bruxism should be noted and watched for.

As most of the medications for the treatment of BD list xerostomia as an adverse effect, signs of dryness in the oral cavity--decay, plaque accumulation, gingivitis, and diminished taste acuity (28)--should be noted and evaluated. Recommendations for management of xerostomia include drinking water or letting ice melt in the mouth; restricting caffeine intake; saliva substitutes; saliva stimulation through chewing sugarless gum or candies; pilocarpine solution; cevimiline, or bethanechol tablets. In-office fluoride administration as well as at-home rinses are also advocated. (1,9,34)

Due to interactions between local anesthetic and the various medications used to treat BD, administration of local anesthetics should be limited. (1,9,34) The practitioner should use, when necessary, 1:100,000 epinephrine and limit administration to two cartridges. (1,9,34)

During periods of depression or institutionalization, oral health is often severely neglected. (37) Oral health promotion does not seem to be a priority even in institutions with a health care team that includes a dentist available within the hospital, and despite the presence of numerous predisposing factors for oral disease such as medications with oral side effects, smoking, and high intake of sugar among patients. (37) Even for those clients with bipolar disorder who are not institutionalized, oral health may not be a major concern within the scope of the clients' overall health problems. (37) Dental hygiene management for the client with BD has been summarized in table 1.

In order to find an answer as to why this situation may exist, it is necessary to explore where oral health fits into the framework of human needs and Maslow's Hierarchy of Needs (figure 1). The basic concept of the pyramid is that the higher needs on the pyramid come into focus only when the lower needs have been met, that is, once the physiological needs are met, then safety needs can be met, and so forth. The bottom four needs, physiological, safety, love/belonging, and esteem, are termed deficiency needs because they indicate deficiencies that must be met before one can achieve self-actualization. (41)

For example, a dental hygienist, because of her knowledge and experience of oral disease and the link between dental and overall health, may place dental health needs near the bottom of the pyramid, at the physiological hierarchy (the need for a sound dentition for physiological function) or at the safety hierarchy (the need for safety from oral disease). However, a person with BD may place oral health needs higher on the pyramid, that is, oral health may be linked to quality of life as opposed to a function for healthy living. This frame of reference would place oral health at the level for esteem (for the cosmetic attributes of a healthy dentition) or self-actualization (as something linked to a higher quality of life), not a resource for health. The individual's health concerns may include maintaining mental wellness, grappling with depression, and freedom from psychosis and suicidal ideation. In the face of these major issues, oral hygiene may be seen as unimportant or superfluous. (37)

The Human Needs Conceptual Model of Dental Hygiene practice is another framework that has been used to view clients and the value they place on dental hygiene care for improving quality of life. (42) Closely linked to the Maslow's hierarchy of needs, the major premise of the model is that human activity is dominated by behaviours aimed at need fulfillment and that when a human need is unmet, an internal drive exists in all human beings to satisfy that need. (42) The human needs defined by the model include the need for a wholesome facial image, protection from health risks, biologically sound and functional dentition, skin and mucous membrane integrity of the head and neck, freedom from head and neck pain, freedom from anxiety and stress, responsibility for oral health, and conceptualization and understanding. To the dental hygienist, dental hygiene diagnosis for a client with BD may include deficits in all of these areas. The client, however, may not see these deficits as deficiencies that need to be filled. The client may be concerned with the daily living aspects associated with bipolar disorder; depression, mania, psychotic delusions, suicidal ideation. He or she may not feel that those needs are a priority or may not have the resources to fill those needs perceived by the dental hygienist. Certainly, if the client does not believe that oral health needs are important, the oral health of the client will suffer and the efficacy of the dental hygienist is severely limited.

[FIGURE 1 OMITTED]

It is critically important for dental hygienists to acknowledge this difference in perspective for viewing the importance of oral health care, because it is the client who needs to maintain his/her own oral health between dental hygiene visits. It is important to have realistic expectations for clients with BD. If oral health is seen as a quality of life as opposed to a functional health issue by the client, then the client may feel that it is either unimportant or unattainable. Evidence indicates that, even in a subsyndromal state, individuals with BD have a lower quality of life than those of the general population. (43) This discrepancy in quality of life means that individuals with BD may have different needs and priorities as far as overall health (and this includes oral health) is concerned.

THE ORAL HEALTH-RELATED QUALITY OF LIFE MODEL

The Oral Health-Related Quality of Life model (OHRQL) posits that a satisfactory level of oral health, comfort, and function as defined by the individual or population is an integral component of general health. (44) This model measures health and disease along a dynamic continuum that includes health and pre-clinical disease, biological/physiological variables, symptom status, functional status, general and/oral health, and overall quality of life. The model also includes social, cultural, and economic characteristics that influence the other domains listed. Within this framework, we can view the client with bipolar disorder's oral health quality of life.

Under the health and pre-clinical disease domain, an individual with bipolar disorder, as previously discussed, is predisposed to oral disease and may exhibit undetectable changes in the oral cavity that could lead to disease. At this stage, prevention and oral health education are key interventions. The biological and physiological domain includes clinically evident disease as well as clinically evident factors that lead to disease such as xerostomia. The impact of bipolar disorder on oral hygiene habits is important in this domain. The dental hygienist should attempt to assess how well the client is managing his/her illness and the impact of the illness on the oral condition. Management of xerostomia and interventions to restore integrity to the oral cavity are important at this stage. The symptom status domain includes the individual's feelings and perception of the disease. This is where the discrepancy between the dental hygienist's priorities and those of the client may lie. The dental hygienist must work within the client's framework for understanding the symptom status in the larger context of the client's overall health. How does the client perceive his oral health, and what is his/her motivation to improve oral health? These are questions the dental hygienist needs to answer in order to better serve the client. The functional status of the client's oral cavity may be limited by the oral effects of bipolar disorder, and chewing, eating, or speaking may be affected. The relationship between symptom status, functional status, and health perceptions domain is important, and oral health education is an important intervention for the dental hygienist to link the impaired functional status with oral health behaviours in order to facilitate change. The dental hygienist should always be mindful of the client's symptom status and health perceptions, however, and be realistic about the client's capacity for much change. As previously mentioned, individuals with bipolar disorder have a generally lower quality of life than the general population. The situation may not be ideal, but if clients are contributing as much as they can to their oral health according to their capacities and motivation, then it is the best that can be done for the clients at that given time.

Under the OHRQL framework, psychosocial functions for the individual with bipolar disorder should facilitate dental hygiene actions such as taking the initiative to contact social workers and the client's physician, and speaking with caregivers in order to provide the most comprehensive care to the client. The client should be encouraged to follow up on psychosocial interventions for management of bipolar disorder as this has been shown to improve prognosis. (4,7,9,11,18-20,23,32) It is under this domain that maintaining a positive relationship with the client is key because clients are more likely to succeed in treatment if they have a positive relationship with the care providers. (45)

Maintaining a positive relationship with the client, based on the client's context and current capacities, and encouraging the client to maintain a positive relationship with his/her physician is of paramount importance. Evidence indicates that an individual's success in treatment is likely positively correlated to the individual's attitude about the treatment and hope in the success of the treatment. (45) The dental hygienist should be a resource for the client to decrease hopelessness whenever possible, and maintaining a positive attitude may enhance the process. Regardless of how deteriorated the oral health, the dental hygienist should point out the areas of the mouth that are healthy, and not just areas that are unhealthy, to provide the client with some positive feedback. The possibility for change in the future must be upheld to support a positive viewpoint for the client. It has been seen that individuals who have shown success in treatment of bipolar disorder have had a sense of control over their illness, (30,45) and the importance of this sense of control should be extrapolated to the effects of bipolar disorder on oral health as well. It is critical that the dental hygienist focus on what the client can control and do about their oral condition.

CONCLUSION

Bipolar disorder is a complex, chronic, and cyclic mental illness that affects all aspects of an individual's life, including oral health. Clients with bipolar disorder have special needs, motivation issues, and differing priorities than the general population. These clients may require more aggressive prevention of dental disease and more comprehensive oral health education. The dental hygienist must keep these needs and client priorities in mind when planning treatment for the client with bipolar disorder.

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This article has been peer reviewed.

by Lori Rosmus, RDH, BSc,* and Sandra J. Cobban, RDH, MDE**

* Private practitioner; corresponding author, [e-mail]

** Assistant Professor, Dental Hygiene Program, Department of Dentistry, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta. Student in PhD program.

Manage oral side         1. Make adjustments in treatment for
  effects of medication     parkinsonian muscle symptoms, drooling
                            - Bite block
                            - Use of low-volume suction during
                              treatment
                         2. Look for signs of damage: gingival trauma,
                            toothbrush abrasion, bruxism
                            - Oral health education
                            - Soft toothbrush
                            - Referral to DDS for mouthguard
                              fabrication
                         3. Look for signs of xerostomia
                            - Oral dryness
                            - Decay
                            - Heavy plaque accumulation
                            Management of xerostomia
                            - Drink water, let ice melt
                            - Restrict caffeine intake
                            - Chew sugarless gum/candies
                            - Pilocarpine, cevimiline, bethanecol to
                              stimulate saliva
                            - Saliva substitutes
                         4. Look for signs of poor/inadequate nutrition
                            - Gingival inflammation
                            - Breakdown of mucosal tissue
                            - Periodontal destruction
                            - Underweight/unhealthy appearance
                            Management of poor/inadequate nutrition
                            - Advise on adequate nutrient intake
                            - Consult with physician or dietician
                         5. Look for signs of alcohol/illegal drug abuse
                            - Erosion of tooth structure
                            - Missing teeth
                            - Periodontal disease
                            - Suspicious lesions
                            - Rapid decay
                            Management of alcohol/illegal drug abuse
                            - Refer to counseling/physician/dietician
                              as appropriate
                            - Educate patient on oral effects of
                              alcohol/illegal drug abuse
Prevent decay            Oral health education, nutrition
                         In-office fluoride treatment--gel or varnish;
                           depending on capacities of client, at-home
                           fluoride rinse
Limit administration
  of local anesthetics
Be realistic             Assess the client's motivation for oral health
                           maintenance
Be a resource for the    Refer client to groups such as the Organization
  client coping with BD    for Bipolar Affective Disorders
                         Encourage client to communicate with physician
                           about the client's concerns over treatment
                         If the client consents, discuss the client's
                           status with his/her physician
                         Maintain that, with proper treatment, there is
                           hope for the client, that treatments are
                           individual, and it may take some time before
                           the client finds the right treatment for them
Refer severely           Ask about suicidal thoughts
  depressed clients      Ask about relationship with physician
                         Encourage client to access help

Table 1. Dental hygiene management of for the patient with bipolar
disorder