Mini-Review :
Khamis A Hassan and Salwa E Khier Dentists are not trained in dental school to
identify and recognize patients with Somatic Symptom Disorder (SSD) before
initiating dental treatment. Lack of such recognition could result in
misdiagnosis, inefficient management of treatment time, and dental treatment
failure. The aim of this mini review is to develop awareness and provide basic
knowledge about SSD among dentists. Several recommendations are made to assist
dental students and dentists in attaining basic knowledge and training related
to this psychiatric disorder. Dentists
are trained in dental
schools to provide treatment for patients with
straightforward health problems that respond to routine dental therapy.
Reviewing the current dental literature reveals that psychology and psychiatry
are not included as subjects in the dental curricula of undergraduate or
postgraduate education. It
is not uncommon that persons might have SSD without being aware of it, simply
because they have never visited a psychiatrist. Many general
dental practitioners might have encountered such
persons in dental practice without recognizing the clinical presentation. Lack
of recognition of SSD in dental patients could result in misdiagnosis,
inefficient management of treatment time, and dental treatment failure [1]. The
dental literature lacks in-depth information regarding how to identify persons
with SSD before initiating dental
treatment. The aim of this mini-review is to
develop awareness and provide basic knowledge about SSD among dentists. This
would assist them in recognizing SSD in undiagnosed persons who seek dental
treatment and prevent dentists from initiating extensive treatment before
managing this disorder. For a more systematic understanding of SSD, its
definition and causes, epidemiology, diagnostic procedures, and treatment
methods are to be described below. SSD
is a quite common psychiatric condition characterized by preoccupation with
physical symptoms that are attributed to a psychologic
disorder rather than organic disease. The exact
cause of SSD is not clear. However, it seems to be associated with any of the
following traits, or a combination of them: (1) genetic traits, e.g. pain
sensitivity, (2) a personality trait that involves negative emotions and poor
self-image, (3) difficulty dealing with stress (4), decreased emotional
awareness, which can make patients focus more on physical issues than emotional
ones (5), learned behaviors, e.g. getting attention from having an illness or
increasing immobility from pain behaviors [2]. SSD
usually starts before the age of 25 or 30, although it can begin in
adolescence, and can last for many years. This disorder appears to be more
common in women than men, with a lifetime prevalence of 0.2 to 2 percent in
women compared with less than 0.2 percent in men. This disorder ranges from
mild to severe and from general to very specific [3]. Persons
with SSD complain of persistent or recurrent vague physical symptoms
accompanied by dysfunctional cognitive, affective, or behavioral reactions.
Diagnosis of SSD relies on three main criteria which include somatic symptoms,
excessive thoughts, feelings, and behaviors, as well as chronicity. The first
criterion of ‘somatic symptoms’ denotes one or more symptoms that result in
disruption of daily life. While, the second criterion of ‘excessive thoughts,
feelings and behaviors’ entails the presence of somatic symptoms or associated
health concerns. To meet this criterion, at least two of the following are
needed: high level of health-related
anxiety, disproportionate and persistent
concerns about the medical seriousness of symptoms, and excessive time and
energy devoted to these symptoms or health concerns. Whereas the third
criterion of ‘chronicity’ refers to a duration of typically greater than 6
months [4,5]. The
distinctive sign to recognize SSD is that symptoms cause a severe impact on
daily activities with inability to frequently school or work and inability to
pursue hobbies or sport activities. Patients usually spend much time at home
and have limited relationship with peers. So, the effects of symptoms on
thoughts and behaviors are more important than the symptom itself. The
disproportion between reported symptoms and the severe limitations in daily
activities should be used as a diagnostic clue [6]. Management
of mental disorders including SSD is provided by mental health professionals. It
focuses on helping the person with SSD to live as much of a normal life as
possible. The two modalities used for managing SSD are Cognitive
Behavior Therapy (CBT) and Mindfulness-Based
Therapy (MBT). CBT is the most consistently supported treatment for SSD. It
helps patients find ways to reframe and gain control of their situation, and
break what can become a self-fulfilling cycle of pain and despair. CBT uses
specific techniques which include relaxation training, problem-solving,
visualization, biofeedback, exercise, and breathing techniques. MBT; the second
management modality, helps patients increase their awareness of what they are
sensing and feeling in the moment, without interpretation or judgment. The
practices used involve various breathing techniques and guided imagery to relax
the body and mind and help reduce stress [7]. In
the dental office, patients with SSD typically present complaining of certain
physical symptoms without identifiable causes. Such symptoms are known as Medically
Unexplained
Oral Symptoms (MUOS) [8,9]. MUOS may be the first or
only manifestation of a mental health problem including chronic orofacial pain,
occlusal discomfort, burning mouth syndrome, salivary gland complaints, atypical
odontalgia, phantom bite syndrome, oral cenesthopathy (Oral Dysesthesia) and halitophobia
and preoccupation with dentures [10-17]. Temperomandibular
Disorder (TMD) is another example of
psychiatric-related complaints in the dental office [18]. The TMD has symptoms
like those of SSD which are sometimes difficult to be differentiated. Lack
of detection and identification of SSD by dental practitioners can result in
inappropriate dental treatment, e.g. dental surgeons might provide TMD patients
with unnecessary and irreversible surgical treatment although their physical
symptoms could be due to mental disorders. After completion of dental
treatment, patients frequently report back to dental office with persistent
symptoms and require dentists to re-evaluate their dental work. Re-examining of
these patients still do not detect any organic pathology related to such
symptoms [4,5]. In an attempt to address the patients’ suffering, dentists may
feel pressure to intervene with further treatments such as replacement of
fillings, providing endodontic treatment, or even extracting the tooth. However,
these dental
re-treatments result in no improvement of persistent
symptoms and cause additional distress and impairment [7]. In
medicine, it is a common practice that surgeons tend to rely on a psychiatric
evaluation prior to initiating invasive and permanent procedures, e.g. cosmetic
plastic surgery. This evaluation is done to either
exclude inappropriate candidates or develop a plan for management [19]. As for
the dental practice, a number of primary care activities can be conducted in
the office such as screening of diabetics and managing hypertension
[20]. Additionally, dental patients are never referred to a psychiatrist nor
screened in dental office for psychiatric illnesses prior to initiating
extensive dental procedures, e.g. placing dental implants especially in
maxillary anterior region of the mouth. Failure to screen for psychiatric
illnesses leaves the dentist and the patient susceptible to extreme likelihood
of time consuming and costly dental problems. Efforts
are warranted to provide practicing dentists with basic knowledge about SSD in
the form of seminars, courses, and/or workshops, along with short training
courses on screening dental patients for SSD. It is further recommended that basic
psychiatric assessment training programs be
incorporated in dental curricula at undergraduate or postgraduate levels. Upon
detection of a patient with SSD, it is advised that dentist/dental student
makes a consultation with the patient’s family doctor and other health
providers involved prior to initiating any dental treatment. This is done to
either exclude inappropriate candidates or develop a plan for management. Additional
efforts should be made towards establishing a psychiatric
consultation liaison service in dental centers to
assist dental practitioners in diagnosing and managing patients with SSD prior
to initiating any invasive dental treatment.
Somatic
Symptom Disorder should be strengthened in dental
education, and screening of dental patients for SSD should be paid attention to
in dental practice. Dental
students and dentists should be trained to recognize
patients attending the dental office with SSD. Failure of such recognition
leaves the dentist and the patient susceptible to extreme likelihood of
additional distress, time consuming and costly dental problems. Khamis A Hassan, Professor of
Restorative Dentistry, Global Dental Center, Vancouver, British Columbia,
Canada, E-mail: globaldental@shaw.ca
Hassan KA and Khier SE. Developing knowledge among
dentists about somatic symptom disorder in dental patients- A mini review (2020)
Dental Res Manag 4: 39-41. Dentist, Student, Somatic symptom disorder,
Medically unexplained oral symptoms, Awareness, Knowledge, Psychiatric,
Consultation liaison.Developing Knowledge among Dentists about Somatic Symptom Disorder in Dental Patients-A Mini Review
Abstract
Full-Text
Introduction
Conclusion
References
Keywords
