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 .
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 .
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 .
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 .
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 .
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 . 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 .
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 . 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 . 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.
- Dimsdale JE and Dantzer R. A biological substrate for somatoform disorders: importance of pathophysiology (2007) Psychosom Med 69: 850-854. https://doi.org/10.1097/psy.0b013e31815b00e7
- Henningsen P. Management of somatic symptom disorder (2018) Dialogues Clin Neurosci 20: 23-30.
- Diagnostic and statistical manual of mental disorders (2013) American Psychiatric Association (5th Edition, DSM-5). https://doi.org/10.1176/appi.books.9780890425596
- Witthöft M and Jasper F. Encyclopedia of mental health (2nd Edition) (2016), Science Direct, United Kingdom, 211-214.
- Lipowski ZJ. Somatization: The concept and its clinical application (1988) Am J Psychiatry 145: 1358-1368.
- Gozzi G and Barbi E. Facing somatic symptom disorder in the emergency department (2019) J Paediat Child Health 55: 7-9.
- Matsuoka H, Chiba I, Sakano Y, Toyofuku A and Abiko Y. Cognitive behavioral therapy for psychosomatic problems in dental settings (2017) Bio Psychosoc Med 11: 18. https://dx.doi.org/10.1186%2Fs13030-017-0102-z
- Toyofuku A. Psychosomatic problems in dentistry (2016) Bio Psychosoc Med 10: 14.
- Kalkur C, Sattur AP and Guttal K. From brain to dentistry: oral psychosomatic disorders-A review (2019) EC Dental Science 18.6: 1189-1196.
- Van der Laan GJ, Duinkerke ASH, Luteijn F and Poel CMA. Role of psychologic and social variables in TMJ Pain Dysfunction Syndrome (PDS) symptoms (1988) Community Dent Oral Epidemiol; 16: 274-277. https://doi.org/10.1111/j.1600-0528.1988.tb01773.x
- Jerlang BB. Burning Mouth Syndrome (BMS) and the concept of alexithymia. A preliminary study (1997) J Oral Pathol Med 26: 249-253.https://doi.org/10.1111/j.1600-0714.1997.tb01232.x
- Votta TJ and Mandel L. Somatoform salivary complaints, Case reports (2002) NY State Dent J 68: 22-26.
- Takenoshita M, Sato T, Kato Y, Katagiri A, Yoshikawa T, et al. Psychiatric diagnoses in patients with burning mouth syndrome and atypical odontalgia referred from psychiatric to dental facilities (2010) Neuropsych Dis Treat 6: 699-705. https://doi.org/10.2147/NDT.S12605
- Tomar B, Bhatia NK, Kumar P, Bhatia M and Shah R. The psychiatric and dental interrelationship (2011) Delhi Psych J 14: 138-142.
- Umezaki Y, Miura A, Watanabe M, Takenoshita M, Uezato M, et al. Oral cenesthopathy (2016) BioPsychoSoc Med 10: 20. https://dx.doi.org/10.1186%2Fs13030-016-0071-7
- Imhoff B, Ahlers MO, Hugger A, Lange M, Schmitter M, et al. Occlusal dysesthesia-A clinical guideline (2020) J Oral Rehabil 47: 651-658. https://doi.org/10.1111/joor.12950
- Naidu J, Bhattacharya P, Mendonsa JP, Manju M and Satish K. Management of chronic atypical facial pain of psychogenic origin: A unique case report (2020) Int J Clin Pediatr Dent 13: 196-198. https://dx.doi.org/10.5005%2Fjp-journals-10005-1729
- Pakhurst CL. Controversies in the aetiology of temporomandibular disorders. Part 1. Temporomandibular disorders: All in the mind? (1997) Prim Dent Care 4: 25-30.
- Sansone RA and Sansone LA. Cosmetic surgery and psychological issues (2007) Psychiatry (Edgmont) 4: 65-68.
- Gambhir RS. Primary care in dentistry-An untapped potential (2015) J Family Med Prim Care 4: 13-18. https://doi.org/10.4103/2249-4863.152239
Khamis A Hassan, Professor of Restorative Dentistry, Global Dental Center, Vancouver, British Columbia, Canada, E-mail: email@example.com
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,