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within primary care could have occurred in waysother than our extra-mural service, but howeversuch developments come about they do seemnecessary for primary care to become an effectivesite for mental health promotion.

AcknowledgementsThe funding for this project came from theMerton, Sutton and Wandsworth Health Authority's Specialist Health Promotion Service, forwhose support we are grateful. We thank DrRichard Chegwidden for his initial support forthe project, and Dr Vino Frances, Dr Mary-EllenWhite. Ms Julie Belfield. Ms Saira Razzaq and MsMichelle Brown for their contribution to theproject.

ReferencesBROWN.M.. GELLEARD.C. & LOBO.R. (1997) Health In Mind.

A Mental Health Promotion Service in Primary Care.

Evaluation Report. London: Merton. Sutton andWandsworth Health Authority. Department of PublicHealth.

HODGSON.R. & ABBASSI,T. (1995) Effective Mental HealthPremonition: A Review of the Effectiveness of HealthEducation and Health Promotion. Technical reportNo. 13. Cardiff: Health Promotion Wales.

TILFORD.S., DELANEY.F. & VOGELS,M. (1997) Effectivenessof Mental Health Promotion Interventions: A Review.London: Health Education Authority.

TUDOR-SMITH.C. (1997) Commentary. In Effectiveness ofMental Health Promotion Interventions: A Review (edsS. Tilford. F. Delaney & M. Vogels). London: HealthEducation Authority.

•¿�ChrisGilleard, Director of Psychology. Pathfinder Mental Health Services, NHS Trust.Springfield University Hospital, Tooting. LondonSW17 7DJ; and Ros Lobo, Mental Health PrimaryCare Facilitator. Merton Sutton and WandsworthHealth Authority Specialist Health PromotionService, Mitcham, Surrey

'Correspondence

Nature and extent of dentalpathology and complicationsarising in patients receiving ECTNita Beli and Peter Bentham

Thisstudy aimed to describe the prevalence of dentalpathology in patients receiving electroconvulsivetherapy and to prospectively determine the incidenceof dental complications arising during treatment. Of 30subjects, 93%complained of a dry mouth and 83%weretaking drugs with anticholinergic properties. A thirdwore dentures and the dentate population had a meanof 15decayed, missingor filled teeth. Oral hygiene andperiodontal condition was poor with one-third requiringscaling and 30% complex periodontal treatment.Temporomandibular pain followed 44% of treatments,and minor buccal lesions occurred in 22%. Greateremphasis must be placed on dental care, andguidelines are suggested to improve practice.

Injuries to teeth and oral soft tissues are wellknown risks associated with electroconvulsivetherapy (ECT). The muscles of mastication aredirectly depolarised by the electrical stimulusbypassing the effect of the muscle relaxant.High stresses are produced during the forcefulclosure of the jaws. The incisors are particularlyat risk as they are normally inclined forwards.Strong occlusal forces will tend to rotate themon a transverse axis, the risk of damage beinggreater if malocclusions such as deep overbites,proclinations or retroclinations are present(Durrani, 1966). Uneven load distribution mayresult in the fracture or loosening of posterior

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teeth which if aspirated may cause seriouscomplications.

Soft tissue lesions arise when the tongue,cheeks and lips get caught between the teeth orbetween the teeth and the mouthguard. Unopposed teeth may lacerate the gums in theopposite arch.

In periodontal disease there is gradual loss ofconnective tissue and résorptionof the alveolarbone leading to loosening of the teeth. Cariescan undermine the enamel of a crown or erodethe neck of a tooth increasing the risk offracture. Full dentures are usually removedprior to treatment but the situation regardingpartial dentures and fixed prostheses is morecomplex.

An oral protective device is recommended inthe routine practice of ECT with the aim ofoptimally distributing the occlusal load andprotecting soft tissue from injury. The use ofthese devices in oral protection is well reviewedby Minneman (1995).

The American Psychiatric Association liabilityinsurance programme receives few claims inrelation to ECT, however a significant proportion of these are for dental injury (Slawson,1989). Despite the clear importance of dentalissues, little practical advice is given in TheECT Handbook (Royal College of Psychiatrists.1995).

The aims of this study were to determine theprevalence and nature of dental disease inpatients receiving ECT and to prospectivelydetermine the incidence of oral soft tissue anddental complications arising during treatment.The findings, together with information from theliterature, are utilised to formulate guidelines ondental management for ECT.

The studyThe study population included all patientsreceiving ECT during a four-week period andall patients who had undergone treatmentduring their current admission to the QueenElizabeth Psychiatric Hospital in Birmingham. Astructured interview and dental examinationwas conducted. Subjects were asked about: oralhygiene habits; frequency of visits to the dentist:oral, dental and jaw problems together with ahistory of relevant physical illnesses and drugtreatment. The case notes were examined andan ICD-10 (World Health Organization. 1992)diagnosis allocated. All subjects had an extra-oral assessment of the neck, mandible andtemporomandibular joint. Intra-orally soft tissues were assessed together with the number ofintact, decayed, missing and filled teeth. Mobileand broken teeth were identified and plaquedeposits recorded using a plaque index. The

peridontal condition of each sextant was assessed utilising a basic peridontal examination(BPE) probe (Ainamo et al, 1982). The presenceand condition of removable and fixed prostheseswas recorded. Particular attention was paid tothe presence of increased overbites, severeproclinations and retroclinations. Patients wereobserved during ECT for abnormal sounds andbleeding. The post-ECT examination was conducted within one hour of treatment. Patientswere asked about pain in the teeth, temporomandibular joint and muscles of mastication.The tongue, buccal and labial mucosae, teethand restorations were examined for signs oftrauma.

FindingsAll patients admitted to hospital who werereceiving ECT treatment or who had had ECTduring their current admission were interviewed:only one patient was excluded because of severepsychotic symptoms. Thirty patients were interviewed, with a mean age of 47 years (range 20-82). There were seven males (23%) and 23females (77%). Some form of depressive episodeaccounted for 93% of subjects, with one case ofemotionally unstable personality disorder andone case of schizophrenia making up the total.Only one subject was totally medication free and83% were taking drugs with anticholinergicproperties and capable of inducing xerostomia(dry mouth). Symptoms suggestive of temporomandibular joint dysfunction (pain and clicking) were found in 13 (43%) subjects and four(15%) complained of toothache. The most common symptom was xerostomia, occurring in 93%of subjects. Drugs with anticholinergic properties were being taken by 86% of this group.Artificial means of keeping the mouth moist wereutilised by two-thirds. Drinking sugary softdrinks and sucking boiled sweets were particularly popular, but only one patient used anartificial saliva spray obtained from a dentist.

Soft tissue abnormalities were found in 16(53%), including aphthous ulcération,geographictongue, denture stomatitis, desquamatlve gingivitis and in a patient suffering from Crohns'disease, lip swelling and moderate thickening ofthe oral mucosa was noted. The most prevalentocclusion type was class 2, division I, present in60%.

The study population consisted of 19 (63%)dentate, eight (27%) partially dentate and three(10%) edentulous patients. Three subjects werewearing partial upper dentures, one partialupper and full lower dentures. Four patientswere wearing full upper dentures while havinglower anterior teeth present. Two of the partially

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dentate patients required replacement or repairof their prostheses.

The mean number of sound teeth per dentatesubject was 15. The mean decayed, missing andfilled teeth was 15 (1 decayed, 9 missing and 5filled). The number of sound teeth declinedsignificantly with age. At least one broken toothwas found in 10 (37%) subjects.

Twenty subjects (67%) claimed to brush theirteeth at least twice a day. In contrast onexamination oral hygiene was poor with 16(56%) having heavy interdental plaque accumulation, some with large deposits of calculus(plaque index 2 or 3). Fifteen (50%) lackedregular dental care, visiting the dentist only ifin pain. Financial difficulties and anxiety werethe main reasons given for not having regularcheck-ups.

Twenty-six dentate patients were examinedwith the BPE probe (one patient was notexamined due to a valvular heart defect). Onprobing, 24 (92%) subjects had BPE scores of twoor three, with bleeding at two sites occurring in11 (42%). In six (23%) subjects the peridontaldisease was so severe that some teeth weremobile and clearly a potential hazard duringECT.

A total of 68 treatments were observed and brieforal examinations performed. The most commoncomplaint was of pain in the temporomandibularregion following 44% of treatments. Minor softtissue trauma occurred quite frequently, particularly in the posterior regions of the mouth (Table1). The most serious complication was a fracturedtooth.

CommentThough the sample size was small it wasrepresentative of patients receiving treatmentwithin a large teaching hospital serving aninner-city area. Compliance was good perhapsbecause an oral examination is a standard partof the pre-ECT assessment, but probably a moreimportant factor was that the dental examination

Table 1. Symptoms and signs of oral traumafollowing ECT treatment (n=68)

Symptom/sign Frequency, %

Temporomandibular painBuccal lesionGingival lesionToothacheLabial lesionTongue lesionTooth fractureRestoration fractureDenture damage

44221313331.500

was performed on a ward rather than in thedentist's chair.Xerostomia was very common and often drug

induced. Few patients could recall being givenany advice on how to deal with a dry mouth andmost were adopting maladaptive copingstrategies. Prescription of artificial saliva spraysmay be helpful if this symptom is severe.

The number of decayed missing and filled teethseemed high, however 1988 figures for the meandecayed, missing and filled teeth in West Midlands adults was 16 (1 decayed. 7.6 missing and7.4 filled), suggesting the study population to beslightly better than average. Xerostomia, poororal hygiene, lack of dental guidance, a cario-genic diet and partial dentures may all becontributing to the high rate of caries. Poor oralhygiene is a major cause of peridontal diseaseand was present in over 90% of the sample. Allpatients needed improved oral hygiene, two-thirds required scaling and cleaning and one-third complex peridontal therapy. A centralproblem seemed to be lack of dental educationboth for the patients and their carers, anddespite the high rate of pathology none of thepatients were registered with the hospitaldentist.

Approximately one-half of the sample hadpartial dentures or fixed prostheses. Denturesreplacing the anterior teeth should be removed,however strong prostheses replacing molars andpremolars are often best left in place as theymay stabilise dentition and balance the occlusion. Non-removable prostheses such as crownsand bridges should be assessed as to theirsuitability to withstand strong occlusal force, abridge with a pontic area spanning more thanthree to four teeth may fail due to excessivestrain on the restorations present on the naturalteeth.

Pain in the temporomandibular region wasthe most common post-treatment complaint andmay be due to joint strain, masticatory musclefatigue or the effects of suxamethonium. One-fifth of patients sustained minor soft tissuetrauma to the buccal mucosa, mainly in theposterior regions of the mouth. We felt that twofactors may have contributed to this. First, thepolystyrene disposable mouthguards were ofone size and sometimes did not extend backsufficiently far into the mouth to cover the firstand second molars and displace the buccalmucosa. Second, some anaesthetists failed tosupport the jaw. allowing possible displacementof the guard.

Opinion is divided as to whether all patientsmust have a pre-ECT examination by a dentalpractitioner (McClure, 1969; Weiner & McCall,1992). The high rate of relevant dental pathology would support specialist assessment,however resources are scarce and it is probably

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necessary to take a pragmatic approach with themedical staff screening patients and referringthose thought to be particularly at risk.

We have now introduced clinical guidelines ondental management of patients receiving ECT(Appendix) and would recommend that similarguidelines are widely introduced.

Appendix Guidelines on dentalmanagement for ECT1. Patients should be asked about relevantdental information, including the frequency ofvisits to the dentist, presence of dental restorations and prostheses, symptoms such as toothache, temporomandibular joint pain, loose teethand bleeding gums.2. Patients should undergo a brief oral examination with the aim of identifying:

(d) loose, broken, decayed or missing teeth,gross dental tartar, failed restorations andabnormal occlusions:

(e) removable dental prostheses (denturesand partial dentures):

(f) non-removable dental prostheses (cemented crowns, bridges and dental implants);

(g) soft tissue lesions and swellings:(h) mandibular deformities:(i) temporomandibular joint dysfunction

(popping, clicking, crepitus and locking).

3. Patients with significant dental symptomsor abnormalities on examination (other thansimply being edentulous) should be referredfor an opinion from a dentist with knowledgeand experience of the effects of ECT on oralstructures.4. Consideration should be given to dental risksduring the consent procedure.5. Information on the patients dental stateshould be made available to the ECT treatmentteam, preferably via the ECT treatment card.6. A mouthguard should be used for all patientsincluding the fully dentate and edentulous.7. The mouthguard should be constructed of amaterial that is partly compressible, and extendsufficiently far back into the mouth to separatethe first and second molar teeth. The guardshould displace the tongue and buccal mucosafrom opposing teeth or ridges and avoid overloading anterior dental structures. More thanone size should be available.

8. The decision to retain partial dentures isdependent on the position, composition andstability of the prosthesis, the aim being toevenly distribute the load through structureswith the ability to cope.9. The jaws should be firmly held together byhand pressure on the mandible throughout theseizure in order to prevent the mouthguard frombecoming displaced.10. Attention should be paid to any abnormalsound coming from the mouth during theseizure. The mouthguard must be carefullyremoved and the oral cavity inspected forevidence of bleeding or loose and missing teeth.In recovery the patients should be asked aboutoral pain and difficulty in opening and closingthe mouth. If significant abnormalities areidentified these should be documented and thepatient referred for a post-ECT dental evaluation.

ReferencesAINAMO.J.. BARNES.D.. BEAORIE.G.. et al (1982)

Development of the World Health Organizationcommunity pcridontal index of treatment needs.International Dental Journal. 32. 281-291.

DURRANT.B. (1966) Dental care in electroplexy. BritishJournal of Psychiatry. 112. 1173-1176.

McCLURE. R. E. (1969) A device for preventing dentalinjuries during ECT. Hospital and CommunityPsychiatry. 2O. 357-359.

MINNEMAN,S. A. (1995) A history of oral protection for theECT patient: past, present and future. ConuulsiDi-Therapy. 11. 94-103.

ROYALCOLLEGEOF PSYCHIATRISTS(1995) The ECT Handbook.The Second Report of the Royal College of Psychiatrists'

Special Committee on ECT (Council Report CR39).London: Royal College of Psychiatrists.

SLAWSON.P. (1989) Psychiatric malpractice and ECT: areview of national loss experience. Convulsive Therapy.5. 126-130.

WEINER.R. D. & MCCALL.W. V. (1992) Dental consultationin ECT. Convulsive Therapy. 8. 146.

WORLDHEALTHORGANIZATION(1992) The Tenth Revision ofthe International Classification of Diseases and RelatedHealth Problems (1CD-ÃŒO).WHO: Geneva.

Nita Beli. Final Year Dental Student. BirminghamDental Hospital and School. Birmingham: and•¿�PeterBentham, Consultant in Old AgePsychiatry. The Queen Elizabeth PsychiatricHospital. Edgbaston. Birmingham BIS 2QZ

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