.................... ................................................ ARTICLE

Alex Thomas, MD, DD, Evanthia Lavrentzou, MD, Charis Karouzos, MD, Costas Kontis, MD

Factors which influence the oral condition of chronic schizophrenia patients

The oral health status of 249 indi- viduals with chronic schizophrenia was evaluated by means of the Oral Hygiene Index (OHI-S) and Decayed, Missing and Filled Teeth scores (DMFT). The patients were subdivid- ed as to chronicity of illness and venue of psychiatric treatment (158 inpatients > 10 years’ hospitaliza- tion, 34 inpatients < 10 years’ hospi- talization, and 57 outpatients). The severity of schizophrenia was deter- mined by: the Brief Psychiatric Rating Scale (BPRS), the intensity of negative symptoms of schizophrenia [as measured by the Brief Psychiatric Rating Scale, Negative Symptoms (BPRSNEGS)], and the equivalent dose of chloropromazine (EDC).

This study demonstrated that inpatients had greater amounts of dental disease than outpatients. The extent of dental disease among inpa- tients as measured by both the OHI- S and DMFT scores was directly related to the intensity of schize phrenia (BPRS), magnitude of nega- tive symptoms associated with schizophrenia (BPRSNEGS), and length of hospitalization. DMFT scores were directly related to EDC value.

ental disease and psychiatric disease are the most prevalent problems in the Western

Schizophrenia is a psychi- atric disorder in which thought dis- turbances and personality disorgani- zation lessen the individual’s ability to work and communicate effectively with others.

The clinical symptoms of schizo- phrenia have been divided into ”pos- itives” and “negatives”, which gener- ally correspond to behavioral excess- es and deficit^.^.^ Though negative symptoms are less dramatic than the positive ones, they are responsible for the chronicity of the disorder and fre- quently impede rehabilitation. These negative symptoms are also poten- tially devastating to oral health, since they impair the patient’s desire and ability to exercise preventive oral hygiene.2

The psychiatric treatment of a schizophrenic patient almost always includes antipsychotic medication and psychosocial treatment and may include a period of hospitalization. Neuroleptics-such as pheno- thiazines, butyrophenones, and thio- xanthenes-are the most frequently prescribed medications used to ame- liorate and reduce psychotic symp- toms. Unfortunately, these drugs cause notable anticholinergic side- effects and may result in hyposaliva- tion and chronic xerostomia.68 This decrease in salivary secretions has been associated with rampant dental caries, gingivitis, and candidiasis.6 In

addition, long-term hospitalization leads to decreaseed self-hygiene and further impairs oral health.9

The purpose of this study was to investigate the influence of chronicity and venue of psychiatric treatment, severity and negative symptoms of schizophrenia, and dosage of neu- roleptic medication on oral health.

Methods In this study, 249 chronic schizophre- nia patients were studied. The diag- nosis of schizophrenia was recorded, for each patient, in the official files of the hospital and was made according to the Diagnostic Statistical Manual of Mental Disorders (3rd ed., rev.) criteria of mental disorders.1° Two psychiatrists on the team examined these patients and confirmed the diagnosis of schizophrenia using the above criteria. Alcohol or drug abusers and patients with severe medical problems (ie., cardiac insuf- ficiency, Sjogren’s syndrome, rheumatoid arthritis, diabetes melli- tus) that might affect the oral condi- tion were excluded. Data concerning the duration of illness and hospital- ization were expressed in years. We recorded the neuroleptic medications received by counting the total doses, converted to a chloropromazine equivalent. The severity of the patient’s psychopathology was eval- uated by the Brief Psychiatric Rating Scale BPRS.ll The positive symptoms12 of conceptual disorganization, grandiosity, hostility, suspiciousness,

84 SCD Special Care in Dentistry, Vol16 No 2 1996

hallucinatory behavior, uncoopera- tiveness, and unusual thought con- tent were identified. Negative symp- toms were measured by a subscale of the BPRS (BPRSNEGS) which con- sists of three items: emotional with- drawal, motor retardation, and blunt- ed affect.12J3

The patients were divided into three groups as follows: Group I (n = 158,63.5%), patients who were hospi- talized for over ten years; Group I1 (n = 34,13.7%), patients who were hos- pitalized for up to ten years; and Group I11 (n = 57, 22.9%), outpatients.

All patients were examined by two dentists using WHO14 examina- tion criteria. Both examined the patient at the same appointment, resulting in one set of data per indi- vidual. The Decayed, Missing or Filled Teeth score (DMFT) was used for evaluation of the dental condition of the patient. All caries lesions, restoration types, and absent teeth were charted, including third molars. A tooth was recorded as sound if it showed no evidence of treated or untreated clinical caries. No radio- graphs were used in the dental exam- ination. The Simplified Oral Hygiene Index (OHI-S)15 was also used for the evaluation of oral hygiene status.

Results Two hundred forty-nine patients par- ticipated in the study; 108 were men (43.4%) and 141 were women (56.5%). Their mean age was 50.35 years, with a standard deviation of 13.7 years. Table 1 provides demographic infor- mation for each group.

The mean length of the patients' stay in the hospital was 15.4 years, and the mean duration of their illness was 22.7 years.

As for their oral hygiene condi- tion, we observed that the mean score of the OHI-S scale was 3.83 (SD 1.97). Table 2 shows that, in Group I com- pared with Group 111, most patients tended to present better oral hygiene (Kruskal-Wallis [K-W] one-way ANOVA, chi-square = 60.453, sigma = 0.000).

We also observed that the mean DMFT score for the total sample was

Table 1. Sex and mean age with standard deviations for each group.

Group I1 Group 111 Group I % n % n Yo

Males 72 45.6 7 20.6 29 50.9

Females 86 54.4 27 79.4 28 49.1

Age* (mean 2 SD) 56.28 10.59 41.70 14.33 39.66 11.36

~~

n

~~~~~ ~ ~ ~

* Significant difference noted between Group I and Groups I1 and I11 (p < 0.05).

Table 2. Mean DMFT. BPRS, BPRSNEGS scores and EDC with standard deviations.

Group I Group I1 Group I11

Mean SD

OHI-S 4.56 1.67 3.11 2.10 2.22 1.57

DMFT* 27.17 5.72 18.50 8.81 16.08 7.75

BPRS** 41.79 9.41 40.64 10.76 33.82 8.01

BPRSNEGS*** 11.32 3.14 8.38 3.33 5.57 1.80

EDC 1057.30 1108.20 1258.50 1164.60 740.12 676.74

.~ Mean SD Mean SD ~.

~ ~~ ~~ ~~

* **

Significant difference noted between Group I and Groups I1 and I11 (p < 0.05). Significant difference noted between Group I/Group I1 and Group II/Group I11 (p < 0.05).

*** Significant difference noted among all Groups (p < 0.05).

23.35 (SD 8.36). According to Table 2, DMFT is not at the same level in all three groups. This difference is attrib- utable to the mean rank of the first group (K-W one-way ANOVA, chi- square = 76.727, sigma = 0.000). Patients who had been hospitalized for more than 10 years tended to have higher DMFT scores than those in the other two groups. This differ- ence, as we can see in Table 3, is due to the Missing (M) component of DMFT (K-W one-way ANOVA, chi- square = 62.824, sigma = O.OOO), although the other two components were significantly lower in this group (K-W one-way ANOVA, ch-square = 17.118, sigma = 0.000 for Decayed; K- W one-way ANOVA, chi-square =

19.806, sigma = 0.000 for Filled). Not surprisingly, patients in

Group I had BPRS (K-W one-way ANOVA, chi-square = 26.961, sigma = 0.000) and BPRSNEGS (K-W one- way ANOVA, chi-square = 102.733, sigma = 0.000) scores higher than those in the other two groups of patients. Patients in Group I11 had the lowest scores. In addition, patients in Group I1 received higher doses of EDC, and those in Group I11 received the lowest doses (one-way ANOVA, F = 3.041, sigma = 0.0496).

To detect the extent to which BPRS, BPRSNEGS, equivalent dose of chloropromazine, and length of stay in the hospital are related to DMFT and OHI-S, we obtained bivariate

Table 3. Decayed, missing, filled teeth (DMFT) in the three groups.

Group I Group I1 Group 111

Mean SD

Decayed (D)* 1.33 1.73 2.29 2.19 2.26 1.86

Missing (M)* 20.32 8.82 10.58 9.33 9.68 8.49

Filled (F)* 1.50 2.6 2.76 3.19 2.92 2.89

. -- Mean SD Mean SD

*Significant difference noted between Group I and Groups I1 and I11 (p < 0.05).

SCD Special Care in Dentistry, Yo116 No 2 1996 85

Table 4. Bivariate correlation between DMFT and BPRS,

BPRSNEGS scale, EDC, and LSH.

Table 5. Bivariate correlation between OHI-S and BPRS,

BPRSNEGS scale, EDC, and LSH.

r Significance r Significance

DMFT - BPRS 0.2168

DMFT - BPRSNEGS scale 0.5522

DMFT - EDC 0.1935

DMFT - LSH 0.5164 ~ ~~~

Pearson correlation coefficients. Table 4 reveals significant moderate rela- tionships between DMFT and BPRS, and between DMFT and equivalent dose of chloropromazine. Also, Table 4 shows significant strong relation- ships between DMFT and all three psychiatric variables. Table 5 reveals significant relationships between OHI-S and BPRS as well as BPRSNEG, but no relationship between OHI-S and equivalent dose of chloropromazine.

Discussion This is the first clinical study con- ducted in Greece which has attemp- ted to gauge the impact of schizo- phrenia and its effects-specifically, the length of hospitalization, dose of neuroleptic medication, and extent of negative symptomatology-on the state of the patients' oral health.

The results of our study revealed that outpatients had better oral health than inpatients. Also, long-term hos- pitalization was found to be related to an increase in dental caries and a worsening of oral hygiene. This find- ing confirmed our hypothesis that long-term hospitalization leads to a decrease in self- and oral hygiene, resulting in increased dental caries.l6-I9

We also documented a strong rela- tionship between the negative symp- toms of schizophrenia and the deteri- oration of oral health. This finding is consistent with those of other studies which have shown that negative symptoms of schizophrenia impair a patient's desire and ability to exercise preventive oral hygiene.2,20 Also, it has been stated that chronically hos- pitalized schizophrenia patients tend to have more severe negative symp- toms than those who live in the com- munity, and our study confirmed this fact.21

0.001

0.000

OHI-S - BPRS 0.1424 0.025

OHI-S - BPRSNEGS scale 0.6753 0.000

0.003 OHI-S - EDC

0.000 OHI-S - LSH -~

Last, we found a moderately posi- tive relationship between the dose of neuroleptic medication and the amount of dental caries. This proba- bly resulted from the neuroleptic medication which caused hyposaliva- tion and abetted caries formation 7,22-26

demonstrate that patients with schizo- phrenia-especially long-term-hospi- talized inpatients-should be consid- ered as a high-risk group for severe oral disease. Preventive dental dis- ease programs must be developed by those who work with psychiatric patients. These programs must edu- cate and sensitize psychiatrists and psychiatric nurses to the oral prob- lems of their patients.

The authors are on the staff of the Psychiatric Hospital of Athens, Greece. Correspondence should be directed to Dr Thomas as 4 Speusipou Street, 10673 Athens, Greece.

In conclusion, our findings

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Clark DB. Dental care for the psychiatric patient: chronic Schizophrenia. J Can Dent

Friedlander AH, Liberman RP. Oral health care for patients with schizophre- nia. Spec Care Dent 11:179-83,1991. Barnes T. Issues in the clinical assessment of negative symptoms. Curr Opin Psych

Leach A. Negative symptoms. Curr Opin

Jonstone E. The assessment of negative and positive features in schizophrenia. Br

Stiefel DJ, Truelove EL, Menard TW, Anderson VK, Doyle PE, Mandel LS. A comparison of the oral health of persons with and without chronic mental illness in community settings. Spec Care Dent

Remick PA, Blasberg B, Patterson BD, Carmichael RB, Miles JE. Clinical aspects of xerostomia. J Clin Psych 44:63-5,1983. Rydgren HO. Side-effects of odontologi- cal interest of psychopharmacotherapy. Swed Dent J 69:85-87,1976. 0ilo G, Hatle G, Gad AL, Dahl BL. Wear of teeth in a mentally retarded popula- tion. J Oral Rehabil17173-7,1990. American Psychiatric Association. Diagnostic and statistical manual of men-

ASSOC 58~912-20,1992.

7:35-8,1994.

Psych 4~18-22,1991.

J Psych 755(S~ppl7):41-4,1989.

10612,1990.

~

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

-0.0122 0.851

0.5071 0.000 ~ .... - .-

tal disorders. 3rd ed. Washington, DC: APA, 1987. Overall JE. The brief psychiatric scale in psychopharmacology research. In: Pharmacopsychiatry. Pichot P, editor. Basel: Karger, pp. 67-78,1974. Nachsoni T, Levin Y, Levy A, Kritz A, Neumann M. A double-blind trial of car- bamazepine in negative symptom schizo- phrenia. Biol Psych 35:22-6,1994. Prosser ES, Chernansky JG, Kaplan J, Thieman S, Thomas MS, Becker J et al. Depression, Parkinsonian symptoms, and negative symptoms in schizophrenia treated with neuroleptics. J Nerv Ment Disease 175:lOO-5,1987. World Health Organisation. Oral health surveys. Basic methods. 3rd ed. Geneva: World Health Organisation, pp. 30-9,1987. Green JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc

Thornton J, A1 Zahid S, Campbell V, Marchetti A, Bradley E. Oral hygiene level and periodontal disease prevalence among residents with mental retardation at various residential settings. Spec Care Dent 9:186-90,1989. Horst G. Dental care in psychiatric hospi- tals in the Netherlands. Spec Care Dent

Hede B, Petersen PE. Self-assessement of dental health among Danish noninstitu- tionalized psychiatric patients. Spec Care Dent 12:33-6,1992. Hede B. Dental health behaviour and self- reported dental health problems among hospitalized psychiatric patients in Denmark. Acta Odontol Scand 53:35-40,1995. Creer C, Wing J. Living wth a schizophrenic patient. Br J Hosp Med July: 73-82,1975. Soni S, Mallik A, Reed P, Gaskell K. Differences between chronic schizo- phrenic patients in the hospital and in the community. Hosp Community Psych

Bahn SL. Drug-related dental destruction. Oral Surg 49-54,1972. Friedlander AH, Brill NQ. The dental management of patients with schizophre- nia. Spec Care Dent 6217-8,1986. Butt GM. Drug-induced xerostomia. J Can Dent Assoc 57391-3,1991. Friedlander AH, Kawakami KK, Ganzell S, Fitten LJ. Dental management of the geriatric patient with major depression. Spec Care Dent 13249-53,1993. Smith RG, Burtner AP. Oral side-effects of the most frequently prescribed drugs. Spec Care Dent 14:96-102,1994,

6825-31,1964.

1263-6, 1992.

43:1233-8,1992.

86 SCD Special Care in Dentistry, Vol16 No 2 1996