Qom University of Medical Sciences Journal

Introduction
Psychiatric disorders are the risk factors for oral health. Oral health is important since it plays a crucial role in general health. Poor oral health can be risk factor for serious diseases such as pneumonia and heart diseases. The patients with psychiatric disorders are at risk of physical health problems, including oral/dental problems. Unhealthy behaviors such as smoking, alcohol use, and substance abuse as well as the side effects of psychotropic medications such as the decrease of saliva in particular can lead to the inflammation and paleness of tongue. Oral and dental problems have high prevalence among patients hospitalized in psychiatric hospitals. Oral problems, pain and difficult swallowing in these patients not only can lead to a malnutrition, but also affect their quality of life. Various problems among hospitalized patients in psychiatric hospitals such as low financial status, unemployment, side effects of medications, bruxism, etc., can increase the frequency of oral and dental diseases. This study aims to investigate dental health and oral pathologic lesions in patients with psychiatric disorders hospitalized in Moddarres and Khorshid hospitals in Isfahan, Iran.
Methods
In this descriptive cross-sectional study, 43 women with psychiatric disorders hospitalized in two Modarres and Khorshid hospitals in Isfahan in 2019 were selected. Using a checklist, their demographic information, including age, duration of hospitalization, type of disease, and educational level were recorded. Then, oral and dental cavity examinations were performed by two final-year dental students. Age 12-60 years, hospitalization due to the diagnosis of psychiatric disorders, and no any systemic disease were the inclusion criteria. Those with a systemic disease and lack of cooperation were excluded from the study. Oral examination was done by objective observation and focusing on the areas which have risks of abnormality, such as the floor of the mouth and the sides of the tongue. Lesions were classified based on color (white or red), pigmentation, having inflammation, and presence of ulcers (acute or chronic), and recorded in the checklist. Presence of soft tissue self-inflicted injury was also evaluated by objective observations, based on the medical records of patients, or by asking the attending nurses. The dryness of mouth was also evaluated by assessing the adhesion of a wooden tongue depressor to the surrounding mucosa. All dental examinations were done based on the Decayed, Missing And Filled Teeth (DMFT) index score. Finally, the data were analyzed in SPSS software, version 21 using Fishers’ exact test, Mann-Whitney U test, Kruskal-Wallis test, and logistic regression analysis. P<0.05 was statistically significant.
Results
Of 43 patients with a mean±SD age of 36.7±13.8 years, 72% had oral lesions. The most common lesions were red-white lesions (23.1%) and pigmented lesions (21.2%), while the least common lesion was the black hairy tongue (2%). Moreover, 37.2% of women had dry mouth and 16.3% had self-inflicted oral injury. Fischer’s exact test results showed that the dry mouth was significantly associated with red-white lesions (P<0.001), pigmented lesions (P=0.01), and geographical tongue (P=0.007). Furthermore, the results showed a significant relationship between dry mouth and type of disease (P=0.03). Mann-Whitney U test results showed no significant relationship between dry mouth and duration of hospitalization (P=0.69). Self-inflicted oral injury was significantly associated with acute ulcers (P=0.001), but there was no significant relationship between self-inflicted oral injury and type of disease (P=0.40). The mean score of DMFT index was 12.8. The most common DMFT scores were 10 and 13. Moreover, 67.4% and 14% of patients had dental erosion and dental asymmetry, respectively. Red-white lesions (P=0.005) and geographical lesions (P=0.01) were significantly higher in patients with schizophrenias and severe depression compared to other patients. Kruskal-Wallis test results showed no significant relationship between lesions and patients’ educational level (P= 0.12) and between DMFT score and patients’ educational level (P=0.59).
Discussion
In this study, red-white lesions, pigmented, and geographic lesions in hospitalized women with psychiatric disorders in Isfahan, Iran had a significant relationship with dry mouth whereas it had no significant relationship with the duration of hospitalization. Dry mouth has been evaluated in several studies. Some have suggested that it can be caused by the side effects of antipsychotic drugs, and it has a direct association with temporomandibular joint disorders and oral injury. Saliva moisturizes the oral environment. It prevents mechanical damage to the tissues of the mouth and teeth by softening foods and making chewing easier. Moreover, it helps clean the mouth by washing the oral cavity. Non-significance of the correlation between the duration of hospitalization and dry mouth in our study might be because of low duration of hospitalization.
In this study, oral ulcers were seen more in women with self-inflicted oral injury. According to previous studies, self-inflicted oral injury is also prevalent among patients with psychiatric disorders especially schizophrenia, following hallucination. In our study, after bipolar patients, oral disorders were high in those with schizophrenia, which may be because of the occurrence of hallucination and delusion, or because they pay less attention to their oral and dental health. This result is consistent with the results of other studies. Bertaud-Gounot et al showed that the severity of oral lesions in patients with schizophrenias were higher than in others. Tang et al. also found that oral disorders were higher in patients with schizophrenia, but there was no difference between those with depression and bipolar disorders. Thomas at al. also reported the high prevalence of oral disorders in those with schizophrenia.
Overall, it can be concluded that dry mouth and self-inflicted oral injury are high among hospitalized women with psychiatric disorders in Isfahan, Iran. Regular follow-up in psychiatric patients can reduce the incidence of oral lesions and dental caries, or help in their earlier diagnosis and better treatment.
Ethical Considerations
Compliance with ethical guidelines
This article is a part of the Doctor of General Dentistry thesis under the No. 398641 and code of ethics IR.MUI.RESEARCH.REC.1398.558.
Funding
This article is a part of the Doctor of General Dentistry thesis of students Marzieh Sheikh Rabati and Fatemeh Bahramzadeh under the supervision of professors Faroz Keshani, Neda Kargehi, Zahraqadawi at the Faculty of Dentistry, Department of Pathology, Isfahan University of Medical Sciences. Its financial sponsor was the Faculty of Dentistry of Isfahan University of Medical Sciences.
Authors contributions
Conceptualization and supervision: Faroz Keshani, Neda Tashani and Zahra Qadavi; Methodology, research and writing - main draft: Faroz Keshani, Neda Tashani, Zahra Qadawi, Marzieh Sheikh Rabati and Fatemeh Bahramzadeh; Writing-criticism and editing: Faroz Keshani, Neda Tashani and Zahra Qadavi; Financing: Isfahan University of Medical Sciences; Sources: selected hospitals in Isfahan, Iran.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
This study has appreciated the cooperation of Modarres and Khorshid Hospitals' employees.