CLINICAL STUDY
Bipolar Disorder: Review of Orthodontic and Orthognathic Surgical Considerations Azita Tehranchi, DMD, MS, Hossein Behnia, DMD, OMFS,y and Farnaz Younessian, DMD, MSy Abstract: An increasing number of patients with psychological conditions with or without drug regimens are seeking orthodontic treatment and orthognathic surgery to address jaws dysmorphology. Depression and bipolar affective disorders are relatively common. These disorders may interfere with the presurgical orthodontics, surgical intervention and postsurgical treatments and thus requires careful considerations. The aim of this article is to report of a case with bipolar disorder and review the orthodontics and orthognathic surgery considerations of patients with bipolar disorder. Key Words: Bipolar disorder, depression, drug interaction, orthognathic surgery (J Craniofac Surg 2015;26: 1321–1325)
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atients with psychological disorders are seeking orthodontic and/or orthognathic treatment due to esthetic and functional impairments and the internal motivation for self improvement.1 Bipolar is a common psychiatric disorder that often starts to manifest in late adolescence or early adult twenties, the age at which most of the orthodontic treatments are carried out.2 Therefore, the orthodontists may play a vital role in early diagnosis and referral of these patients because they are the only health care professionals visited by patients on a regular basis.3 So increasing the overall awareness for surgeons and orthodontists about this psychiatric problem is essential for successful management of these cases throughout the course of orthodontic treatment and orthognathic surgery. In addition, the impact of orthognathic surgery on preoperative or postoperative condition of patients with bipolar has not been fully understood yet, and few specific recommendations exist to optimize medication regimens for this population. The potential anxiety-provoking effect caused by anticipatory pain because of the surgical phase of the treatment might increase the need for special considerations in these patients.4 The primary objective of this article is to highlight the orthodontics and orthognathic considerations for patients with bipolar disorder. Bipolar disorder, also named manic-depressive disorder, is a serious psychiatric illness associated with altering prolonged episodes of extreme mania (median duration of four months) and depression (median duration of 6 months).5 This condition has a From the Dental Research Center; and yDentofacial Deformities Research Center, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received June 7, 2014. Accepted for publication November 20, 2014. Address correspondence and reprint requests to Farnaz Younessian, DMD, MS, Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001689
The Journal of Craniofacial Surgery
lifetime prevalence of approximately 1% among the general population with a strong familial pattern.6 The diagnosis is complex mostly based on clinical judgment; this is the main reason that treatment is often not considered until up to a decade after onset of the disorder.7 The differential diagnosis with unipolar depressive disorders and also schizoaffective disorders is critically important. To date, several questionnaires are used as a screening research tool to facilitate the diagnosis of bipolar.8 However, none of them were found to be sensitive enough to be used independently, but concurrent usage of available self-report questionnaires has been shown to be effective in the diagnosis of bipolar patients.9 General characteristic of manic episodes is hyperactivity with excessive participation in multiple social activities without full recognition of the patients.10 Special speaking pattern with loud voice and abrupt alteration in topics are common manifestations of bipolar. During depression phase, patients suffer from insomnia, loss of appetite, sadness, and the decreased energy, which has a strong impact on their daily performances and quality of life.11 Substance abuse and suicide attempts are the most common complications of bipolar disorders in manic and depression episodes, respectively.12 Special medications are available for the treatment of individuals with bipolar disorder at different stages, which requires careful management.13 Acute effective treatment may cause a switch of symptoms (depression to hypermanic and vice versa) and needs close monitoring of the patients. The difficulty arises when the patients do not take their prescribed medication, especially during the depression phase of bipolar.14 Antipsychotic medications, including semisodiualvalporate and carbamazepine, are effective in treating the manic phase of this disorder.15 Acute depressive episode is usually treated with the temporary administration of antidepressant medications, which are available in 4 major groups, including tricyclic antidepressant (TCA), selective serotonin reuptake inhibitors, atypical agents, and monoamine oxidase inhibitors. However, the efficacy of antidepressant in chronic bipolar depression is questionable.16 Recent guidelines recommend gradual decrease in antidepressant drugs over several weeks17 and introduce antipsychotics as a first-line therapy after recovery from the acute depressive phase; both could be given as monotherapy or in conjunction with a mood stabilizer.18,19 Inadequate control of this depression phase may result in significant risk of a manic/hypomanic switch, which is mostly reported by concomitant TCA treatment.19
DIAGNOSIS AND ETIOLOGY A 23-year-old female patient was referred to the orthodontic department with a chief complaint of excessive gingival show on smiling in addition to the mandibular retrusion (Figs. 1 and 2). The patient had a history of bilateral temporomandibular joint ankylosis secondary to mandibular trauma when she was 5 years. This was the main etiology of the severe mandibular deficiency and restricted mouth opening. The patient had undergone previous multiple surgeries for the release the temporomandibular joint ankylosis. On clinical examination, she showed a convex facial profile,
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FIGURE 1. Extraoral (A) pretreatment and (B) posttreatment photographs.
incompetent lips at rest, and excessive gingival show on smile (Fig. 3). Intraorally, mild gingival inflammation was detected which was relevant to her medication history. The dentition was in class II relationship at both sides. The primary lateral cephalometric analysis confirmed the maxillary vertical excess, class II skeletal pattern caused by mandibular hypoplasia, and compensatory proclination of the upper incisors. The panoramic radiograph did not reveal any other pathological findings. With regard to her psychological history, she was emotionally disturbed after her multiple surgeries at childhood and also her facial appearance. As it is stated by her family, she was not able to communicate well in school. She was diagnosed with bipolar disorder when she was 16 years old and hospitalized for 2 months to receive treatment. On investigation of her familial history, it appeared that her mother had a history of depression, which lasted approximately 5 years. The patient’s daily medication regimen included lithium, depakine (valporate sodium), and bipyridine to control her psychological status.
TREATMENT PROGRESS Presurgical orthodontic treatment was carried out to deal with the crowding which lasted for about 12 months which included nonextraction approach and maxillary expansion using Hyrax appliance. She was instructed to maintain at best during the orthodontic phase of the treatment. The decision was made to impact the maxilla at a Le Fort I level and advance the mandible via bilateral sagittal split osteotomy. Frequent consultations with psychiatrist were established during presurgical orthodontics, and an advice was given to perform surgery during the maintenance phase. Psychiatrist prescribed 500 mg phenytoin 1 hour before surgery. She was
FIGURE 2. Lateral cephalometry of the patient (A) before and (B) after treatment.
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FIGURE 3. Pretreatment and posttreatment tracing superimpositions.
ordered to discontinue lithium intake 3 days before surgery, considering a half life of the prescribed drug. During surgery, rigid internal fixation was used to stabilize the osteotomy segments.
TREATMENT RESULTS The radiographic superimposition showed that, as planned, the maxilla moved superiorly, the mandible advanced, and the chin projection improved greatly by advancement genioplasty (Fig. 3). After surgery, cephlosporine, acetaminophen, antihistamine, and fursulfate were prescribed for the patient. She restarted lithium with close control about 1 week after surgery. After surgery, the patient showed manifestations of depression, which rapidly changed to happiness as a result of the achieved improvement in the facial appearance. After 6 months of postsurgical orthodontics (minimum duration), braces were removed, and patient was referred to a periodontist to monitor her periodontal status, considering the side effects of drugs and also to replace the previously extracted molar with an implant-based prosthesis (Fig. 3).
DISCUSSION Presurgical Orthodontics and Considerations Considering the approved guidelines for bipolar patients, it is recommended that before initiation of any type of intervention, updated information on history of medication regimen, level of patient’s cooperation, and overall psychiatric profile should be obtained in consultation with the patient’s psychiatrist. All psychiatric illnesses conditions should be accurately understood before any treatment should be planned, and this may involve seeking guidance from the patient’s psychiatrist.20 To date, many studies have investigated the prevalence and pronounced clinical feature of common psychological disorders like depression and body dismorphic disorder among orthognathic surgical patients.21 There is always a possibility that the observed dentofacial deformity is the main underlying reason of generated psychological disorder. It is very crucial for patients with psychological disorders to clarify the individualized cost and benefits of receiving any optional surgery. It might necessitate receiving multiple steps of consultation with experts on anticipated results, particularly if the surgery would directly impact an aspect that could change the psychological profile of the patient, interactively. Orthognathic surgery could be considered as an optional surgery for a patient suffering bipolar disorder. However, considering the #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
possible impact of the surgical results on facial appearance and consequently on overall psychological status of patients, it needs extra time for clinicians to anticipate advantages and disadvantages of orthognathic surgery for bipolar patients. Caution must be taken about integrity of realistic patients’ and surgeons’ expectations from the surgical procedure.21 We have used supplementary records of previous patients with same dentofacial deformity to help the patient understand her problem and her treatment process. A multidisciplinary team, including surgeon, psychiatrist, psychologist, orthodontist, and general dentist should provide a comprehensive treatment plan. The overall aim of managing these patients must contain relief of malocclusion, maintenance of oral health, and prevent further functional impairment of the patient. Because of the psychiatric status of these patients, orthodontic treatment should be carried out in minimum duration. In most of these conditions, it seems that surgical intervention must be avoided unless distinct soft tissue improvement or serious functional problems are encountered, including condylar ankylosis and restricted jaw functions. However, nonspecific and vague expectation of possible facial improvement by orthognathic surgery must not be considered valid enough to select this treatment regimen for this group of patients. With regard to intraoral oral conditions, bipolar patients suffer from dry mouth due to the antidepressant medication.22 Xerostomia (73%) and generalized stomatitis are common complications of patients under lithium therapy.22 Although the xerostomia following the mood stabilizer drugs is thought to play a role in increased cervical caries rate, this relationship is complex.22 It is also reported that increased usage of saliva-stimulating candies and sweet nutrients by patients as oral lubricants also might worsen the situation. Hypersalivation after lithium therapy also has been reported.23 Preventive dental education for these patients and their families, including reinforcement of daily oral hygiene activities, regular usage of chlorhexidinegluconate mouth rinse to decrease gingival inflammation, and periodic fluoride therapy to reduce the incidence of caries, is the mainstay of orthodontic treatment of these patients.24 In addition, protocol for dry mouth, including commercially available saliva substitutes, sugar-free chewing gums, and other stimulus, must be considered.24 It must be considered that during the manic stage, many patients exhibit abraded oral musoca in combination with various degrees of cervical tooth abrasion caused by unconscious harsh usage of toothbrushes and other oral health aids.25 In contrast, during depression phase, decreased level of oral hygiene may be associated with distinct increase in incidence of dental caries and potential periodontal problems.26 Oral hygiene is critical for successful completion of orthodontic treatment. Visiting patients on their manic episodes, except simple psychiatric considerations to control their restlessness on dental units, need no further interventions.27 However, decreasing the duration of presurgical orthodontics is recommended. Mood switching phenomena for bipolar patients is multifactorial and highly unpredictable, usually based on individual disease patterns.28 If the patient goes through a depression mood, it would be difficult to keeping the regular follow-up appointments. Close cooperation of the patient’s family plays an important role during this phase of bipolarvals. Regular consultation with patient psychiatrist may also be needed until stable psychiatric status could be obtained.20 Gingival overgrowth is another manifestation of using of anticonvulsant drugs (Valproic), which is used routinely during acute manic and maintenance phases.29 In extreme severe conditions, hyperplasia may impede the orthodontic tooth movements and slow the speed of overall treatment. Gingivectomy is not recommended during active treatment, and in extreme conditions, contacting the #
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Surgical Considerations in Bipolar Patients
patient’s psychiatrist to discuss alternative medication is recommended.30 Fortunately, no special medications are required during orthodontic treatments of patients who suffer from bipolar disorder. However, in some occasions, local anesthesia might be used to insert or remove temporary anchorage devices, extractions, or special canine exposure procedures. Various psychotropic medications block the a-adrenergic receptors that are responsible for vasoconstriction in smooth muscles and thereby decrease the vasoconstrictor effect of epinephrine in local anesthesia.31 Shortened duration of local anesthesia and hypotension with secondary tachycardia might be the consequences of interactions with these psychotropic agents.31 Particularly for the patients in the acute depressive phase, who temporarily receive TCAs, sedative medications must be avoided. The potential interaction of these 2 group drugs may cause severe respiratory depression.32 The use of local anesthesia with epinephrine is controversial in this specific phase because of the possibility of develop severe hypertensive crisis; however, many clinicians consider this danger not clinically relevant enough to make a recommendation. However, care must be taken to at least avoid intravascular injection of the epinephrinecontaining local anesthesia.33 Considering the wide range of medications used at different phases of bipolar disorder, only some considerations with lithium and monoamino oxidase are available. Major adverse interactions between lithium and dental medications are not common.26 However, the use of nonsteroidal anti-inflammatory drugs (NSAIDS) similar to some antibiotics like metronidazole and tetracycline may slow the rate of the renal clearance of lithium and consequently, rising the plasma level of the lithium by 40% to 60%; which could lead to toxic effects.23,34 In addition, if the patient is taking selective serotonin reuptake inhibitors at acute depressive phase, risk of intestinal bleeding should have been taken into account at concomitant prescription of NSAIDS.35 On the other hand, the literature indicates that prolonged usage of NSAIDS might decrease the rate of orthodontic tooth movement. Therefore, for bipolar patients under orthodontic treatment, prolonged prescription of NSADIS, such as ibuprofen, is not recommended; however, short-term use of NSAIDS may not pose a problem in this regard.36 Patient’s receiving monoamino oxidase as an antidepressant agent in acute depressive phase should avoid taking sympathomimetic medication and also avoid epinephrine injection.37 Repeated preoperative psychiatrist evaluation before the surgery is recommended to prepare the patient before this intervention.
Orthognathic Surgical Considerations Two main risks should be dealt within patients using psychotropic drugs who undergo elective surgery: first, increased risk through psychiatric drug direct effect and its interaction with anesthesia. Second, the impacts of the temporary withdraw of psychotropic drug and its impact on the patients’ deterioration.38 A stable psychiatric status of the patient is essential before surgical intervention.32 Current psychotropic medication regimen is the main deterministic factor that must be considered to select proper type of anesthesia and type of fixation during surgery.38 Regarding the possible severity grades of reported psychotropic drug interaction, interdisciplinary consultation is highly recommended. The best possible stage for surgery on bipolar patients seems to be during maintenance phase, in which there would be no serious concern about the psychiatric status of the patient. If the patient is on the lithium regimen, lithium discontinuation is recommended.37 Direct effects of lithium might cause hemodynamic instability which is a hazardous risk because of interactions with sodium and potassium metabolism.38 Long time fasting and large fluid loading (needed because of anesthetic technique) which lead to
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acute hypernatremia, necessitates closer monitoring and the possibility of utilizing different anesthetic strategy to avoid this classical complication of chronic lithium therapy.39 Lithium can be discontinued at once because no withdrawal symptoms occur. It is recommended to stop usage of lithium 72 hours before surgery.40,41 Decreasing the lithium level of blood should be done best by perioperative administration of sodium-containing intravenous fluids, not by stimulation of urine output with thiazide diuretics.42 This drug reduces the clearance of lithium and has a reverse effect which can result in toxicity.43 Close electrocardiography monitoring should be done to monitor cardiac abnormalities secondary to lithium toxicity. Declined level of anesthetic agents may be required because of the association of sedative medications with lithium.43 The recommended protocol for patients under antidepressant medication who are undergoing surgical procedure is mostly discontinuing the drug (except selective serotonin reuptake inhibitors) because of possible interactions with the anesthetic agents.38 Another possible drug regimen of bipolar patients at maintenance phase is antipsychotic drugs. The second generation of these drugs (olanzapine, quetiapine, risperidone, zeiprasidone, aripiprazole, and asenapine) decrease the extrapyramidal effects and cardiac changes at electrocardiograph monitoring, which can result in other medical complications.38 Hypotension is a reported hazardous side effect of antipsychotics in combination with many halogenated inhaled anesthetics. These possible hazardous side effects can be easily prevented with the aid of modern anesthetic agents. Considering available evidence and guidelines, it is not recommended to discontinue the first-generation antipsychotics for an elective surgery. However, preoperative electrocardiography should be evaluated considering the side effects of these antipsychotics (eg, prolonged QTc intervals).
Postsurgical Orthodontics and Considerations Orthognathic surgery is a complex process which results in changes in the appearance and functions of the dentofacial structures, including respiration, swallowing, speech, and mastication.38 Adequate presurgical preparation is especially important in bipolar patients.44 Psychological disorders may flare during the postoperative period, and sudden discontinuation of psychiatric medication for a sustained period of time adds to the risk of psychiatric disorders relapse. The unexpected nature of mood swings, which can easily be triggered by a surgical procedure, highlights the importance of case selection and monitoring through the whole process. Active role of psychiatrists in all treatment phases, particularly postsurgical phase is necessary.45,46 The management of possible mood swing depends on its severity could range from a simple behavioral management or altering the mood stabilizer. It is usual for patients to suffer from some depression after orthognathic surgery.43 To date, no study evaluate the impact of orthodontic or orthognathic surgery on psychological profile of patient with serious mental illness. It is important in bipolar patients to restart lithium with close monitoring within 1 week when patients return to the normal diet and are hemodynamically stable.38 Although it has been reported in the literature that psychological well-being of orthognathic patients does not alter with fixation type (wire or rigid), considering other advantages related to oral function and social interaction,47 the use of rigid internal fixation with minimal intermaxillary elastics should be considered to minimize postoperative stress and anxiety. Further studies are needed to optimize every single step of orthognathic surgery for patients with psychological disorders. Ultimate success of surgical treatment modality should be assessed by both occlusal function and morphological improvement, and also changes in the psychosocial wellbeing of affected patients.44
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ACKNOWLEDGMENTS The authors thank Dr. Ashraf Ayoub and Dr. Rebecca Crawford for technical help and writing assistance in this article.
REFERENCES 1. Giglio JA, Laskin DM. Prevalence of psychiatric disorders in a group of adult patients seeking general dental care. Quintessence Int 2010;41:433–437 2. Taylor M, Bressan RA, Pan Neto P, et al. Early intervention for bipolar disorder: current imperatives, future directions. Rev Bras Psiquiatr 2011;33(Suppl 2):s197–s212 3. Kim SJ, Kim MR, Shin SW, et al. Evaluation on the psychosocial status of orthognathic surgery patients. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2009;108:828–832 4. Kiyak HA. The impact of interpersonal support on patient satisfaction with orthognathic surgery. J Oral Maxillofac Surg 1995;53:1279–1299 5. Schatzberg AF. Bipolar disorder: recent issues in diagnosis and classification. J Clin Psychiatry 1998;59(Suppl 6):5–10 6. Geddes J. Bipolar disorder. Evidence Based Mental Health 2003;6:101– 102 7. Noorbala AA, Arbabi M, Shalbafan AR. Psychological dimensions in patients admitted in Imam Khomeini General Hospital in Tehran. Iran J Psychiatry 2010;5:51–54 8. Shabani A, Koohi-Habibi L, Nojomi M, et al. The Persian bipolar spectrum diagnostic scale and mood disorder questionnaire in screening the patients with bipolar disorder. Arch Iran Med 2009;12:41–47 9. Shabani A, Ahmadzad-Asl M, Zangeneh K, et al. Shariat SV Quality of life in patients with bipolar I disorder: is it related to disorder outcome? Acta Med Iran 2013;51:386–393 10. Scully C, Cawson RA. Psychiatric disorders. In: Medical problems in dentistry. 4th ed. Oxford: Wright, 1998; 374–95. 11. Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press; 1990:227-8 12. Song JY, Yu HY, Kim SH, et al. Assessment of risk factors related to suicide attempts in patients with bipolar disorder. J Nerv Ment Dis 2012;200:978–984 13. Fountoulakis KN, Vieta E, Siamouli M, et al. Treatment of bipolar disorder: a complex treatment for a multi-faceted disorder. Ann Gen Psychiatry 2007;6:27 14. Goodwin FK, Jamison KR. Manic Depressive Illness. New York: Oxford University Press; 1990 15. Malhi GS, Tanious M, Berk M. Mania: diagnosis and treatment recommendations. Curr Psychiatry Rep 2012;14:676–686 16. Trevor Young L. What is the best treatment for bipolar depression? J Psychiatry Neurosci 2008;33:487–488 17. The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. NICE clinical guideline, 2006; 27. 18. Bauer M, Ritter P, Grunze H, et al. Treatment options for acute depression in bipolar disorder. Bipolar Disord 2012;214(Suppl):37–50 19. Amit BH, Weizman A. Antidepressant treatment for acute bipolar depression: an update. Depress Res Treat 2012684725. doi: 10.1155/ 2012/684725. Epub 2012 Jan 27 20. Friedlander AH, Mills MJ, Cummings JL. Consent for dental therapy in severely ill patients. Oral Surg Oral Med Oral Pathol 1988;65:179–182 21. Vulink NC1, Rosenberg A, Plooij JM, et al. Body dysmorphic disorder screening in maxillofacial outpatients presenting for orthognathic surgery. Int J Oral Maxillofac Surg 2008;37:985–991 22. Bone S, Roose SP, Dunner DL, et al. Incidence of side effects in patients on long-term lithium therapy. Am J Psychiatry 1980;137:103–104 23. Clark DB. Dental care for the patient with bipolar disorder. J Can Dent Assoc 2003;69:20–24 24. Sjogren R, Nordstrom G. Oral health status of psychiatric patients. J Clin Nurs 2000;9:632–638 25. Friedlander AH, Friedlander IK. Dental management of the patient with major depressive disorder. Oral Health 2001;91:47–57 26. Friedlander AH, Brill NQ. The dental management of patients with bipolar disorder. Oral Surg Oral Med Oral Pathol 1986;61:579–581 27. Friedlander AH, Birch NJ. Dental condition in patients with bipolar disorder on long-term lithium maintenance therapy. Spec Care Dentist 1990;10:148–151 #
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28. Johnson L, Andersson-Lundman G, Aberg-Wistedt A, et al. Age of onset in affective disorders: its correlation with hereditary and psychosocial factors. J Affect Disord 2000;59:139–148 29. Nakib N, Ashrafi SS. Drug-induced gingival overgrowth. Dis Mon 2011;57:225–230 30. Kataoka M, Kido J, Shinohara Y, et al. Drug-induced gingival overgrowth—a review. Biol Pharm Bull 2005;28:1817–1821Review 31. Quock RM. Clinical complications in the psychiatric dental patient. Compend Contin Educ Dent 1985;6:333–334338-40, 342 32. Bookes JL. Adverse reaction to local anesthetics/vasoconstrictor preparations: a study of the cardiovascular response. Br Dent J 1997;133:137–140 33. Hollister LE. Tricyclic antidepressants. N Engl J Med 1978;299:1168– 1172 34. Little JW, Falace DA, Miller CS, et al. Dental management of the medically compromised patient. 5th ed. St. Louis: Mosby; 1997:546-75 35. Bartzela T, Tu¨rp JC, Motschall E, et al. Medication effects on the rate of orthodontic tooth movement: a systematic literature review. Am J Orthod Dentofacial Orthop 2009;135:16–26doi: 10.1016/ j.ajodo.2008.08.016. Review 36. Huyse FJ, Touw DJ, Van Schijndel RS, et al. Psychotropic drugs and the perioperative period: a proposal for a guideline in elective surgery. Psychosomatics 2006;47:8–22 37. Reebye UN, Reebye PN, Cottrell DA, et al. Mood disorders and dental implications. J Mass Dent Soc 2003Fall;52:38-42 38. Attri JP, Bala N, Chatrath V. Psychiatric patient and anaesthesia. Indian J Anaesth 2012;56:8–13doi: 10.4103/0019-5049.93337
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39. Schou M. Lithium treatment during pregnancy, delivery and lactation: an update. J Clin Psychiatry 1990;51:410–413 40. Morgan GE, Mikhail MS, Murray MJ. Anesthesia for patients with neurologic and psychiatric disease. In Morgan: Clinical anaesthesiology, 4th ed USA: LANGE International edition, 2008; 647–61. 41. Vergnaud E, Baudin O, Desachy A, et al. Standard perioperative management of patients treated with lithium can lead to hyperosmolar coma. Ann Fr Anesth Reanim 2007;26:168–170 42. Takashi A, Koh S. A case of atropine-resistant bradycardia in a patient on long-term lithium medication. Masui 2001;50:1229–1231 43. Pavone I, Rispoli A, Acocella A, et al. Psychological impact of selfimage dissatisfaction after orthognathic surgery: a case report. World J Orthod 2005Summer;6:141-8 44. Bellucci CC1, Kapp-Simon KA. Psychological considerations in orthognathic surgery. Clin Plast Surg 2007;34:e11–e16 45. Cunningham SJ1, Feinmann C. Psychological assessment of patients requesting orthognathic surgery and the relevance of body dysmorphic disorder. Br J Orthod 1998;25:293–298 46. Smeele LE, Van der Feltz-Cornelis CM. Professional attitudes to requests for secondary facial reconstruction in patients who have attempted suicide. Br J Oral Maxillofac Surg 1995;33:228–230 47. Hatch JP1, Rugh JD, Bays RA, et al. Psychological function in orthognathic surgical patients before and after bilateral sagittal split osteotomy with rigid and wire fixation. Am J Orthod Dentofacial Orthop 1999;115:536–543
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Bipolar Disorder: Review of Orthodontic and Orthognathic Surgical Considerations Azita Tehranchi, DMD, MS, Hossein Behnia, DMD, OMFS,y and Farnaz Younessian, DMD, MSy Abstract: An increasing number of patients with psychological conditions with or without drug regimens are seeking orthodontic treatment and orthognathic surgery to address jaws dysmorphology. Depression and bipolar affective disorders are relatively common. These disorders may interfere with the presurgical orthodontics, surgical intervention and postsurgical treatments and thus requires careful considerations. The aim of this article is to report of a case with bipolar disorder and review the orthodontics and orthognathic surgery considerations of patients with bipolar disorder. Key Words: Bipolar disorder, depression, drug interaction, orthognathic surgery (J Craniofac Surg 2015;26: 1321–1325)
P
atients with psychological disorders are seeking orthodontic and/or orthognathic treatment due to esthetic and functional impairments and the internal motivation for self improvement.1 Bipolar is a common psychiatric disorder that often starts to manifest in late adolescence or early adult twenties, the age at which most of the orthodontic treatments are carried out.2 Therefore, the orthodontists may play a vital role in early diagnosis and referral of these patients because they are the only health care professionals visited by patients on a regular basis.3 So increasing the overall awareness for surgeons and orthodontists about this psychiatric problem is essential for successful management of these cases throughout the course of orthodontic treatment and orthognathic surgery. In addition, the impact of orthognathic surgery on preoperative or postoperative condition of patients with bipolar has not been fully understood yet, and few specific recommendations exist to optimize medication regimens for this population. The potential anxiety-provoking effect caused by anticipatory pain because of the surgical phase of the treatment might increase the need for special considerations in these patients.4 The primary objective of this article is to highlight the orthodontics and orthognathic considerations for patients with bipolar disorder. Bipolar disorder, also named manic-depressive disorder, is a serious psychiatric illness associated with altering prolonged episodes of extreme mania (median duration of four months) and depression (median duration of 6 months).5 This condition has a From the Dental Research Center; and yDentofacial Deformities Research Center, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received June 7, 2014. Accepted for publication November 20, 2014. Address correspondence and reprint requests to Farnaz Younessian, DMD, MS, Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001689
The Journal of Craniofacial Surgery
lifetime prevalence of approximately 1% among the general population with a strong familial pattern.6 The diagnosis is complex mostly based on clinical judgment; this is the main reason that treatment is often not considered until up to a decade after onset of the disorder.7 The differential diagnosis with unipolar depressive disorders and also schizoaffective disorders is critically important. To date, several questionnaires are used as a screening research tool to facilitate the diagnosis of bipolar.8 However, none of them were found to be sensitive enough to be used independently, but concurrent usage of available self-report questionnaires has been shown to be effective in the diagnosis of bipolar patients.9 General characteristic of manic episodes is hyperactivity with excessive participation in multiple social activities without full recognition of the patients.10 Special speaking pattern with loud voice and abrupt alteration in topics are common manifestations of bipolar. During depression phase, patients suffer from insomnia, loss of appetite, sadness, and the decreased energy, which has a strong impact on their daily performances and quality of life.11 Substance abuse and suicide attempts are the most common complications of bipolar disorders in manic and depression episodes, respectively.12 Special medications are available for the treatment of individuals with bipolar disorder at different stages, which requires careful management.13 Acute effective treatment may cause a switch of symptoms (depression to hypermanic and vice versa) and needs close monitoring of the patients. The difficulty arises when the patients do not take their prescribed medication, especially during the depression phase of bipolar.14 Antipsychotic medications, including semisodiualvalporate and carbamazepine, are effective in treating the manic phase of this disorder.15 Acute depressive episode is usually treated with the temporary administration of antidepressant medications, which are available in 4 major groups, including tricyclic antidepressant (TCA), selective serotonin reuptake inhibitors, atypical agents, and monoamine oxidase inhibitors. However, the efficacy of antidepressant in chronic bipolar depression is questionable.16 Recent guidelines recommend gradual decrease in antidepressant drugs over several weeks17 and introduce antipsychotics as a first-line therapy after recovery from the acute depressive phase; both could be given as monotherapy or in conjunction with a mood stabilizer.18,19 Inadequate control of this depression phase may result in significant risk of a manic/hypomanic switch, which is mostly reported by concomitant TCA treatment.19
DIAGNOSIS AND ETIOLOGY A 23-year-old female patient was referred to the orthodontic department with a chief complaint of excessive gingival show on smiling in addition to the mandibular retrusion (Figs. 1 and 2). The patient had a history of bilateral temporomandibular joint ankylosis secondary to mandibular trauma when she was 5 years. This was the main etiology of the severe mandibular deficiency and restricted mouth opening. The patient had undergone previous multiple surgeries for the release the temporomandibular joint ankylosis. On clinical examination, she showed a convex facial profile,
Volume 26, Number 4, June 2015
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Tehranchi et al
Volume 26, Number 4, June 2015
FIGURE 1. Extraoral (A) pretreatment and (B) posttreatment photographs.
incompetent lips at rest, and excessive gingival show on smile (Fig. 3). Intraorally, mild gingival inflammation was detected which was relevant to her medication history. The dentition was in class II relationship at both sides. The primary lateral cephalometric analysis confirmed the maxillary vertical excess, class II skeletal pattern caused by mandibular hypoplasia, and compensatory proclination of the upper incisors. The panoramic radiograph did not reveal any other pathological findings. With regard to her psychological history, she was emotionally disturbed after her multiple surgeries at childhood and also her facial appearance. As it is stated by her family, she was not able to communicate well in school. She was diagnosed with bipolar disorder when she was 16 years old and hospitalized for 2 months to receive treatment. On investigation of her familial history, it appeared that her mother had a history of depression, which lasted approximately 5 years. The patient’s daily medication regimen included lithium, depakine (valporate sodium), and bipyridine to control her psychological status.
TREATMENT PROGRESS Presurgical orthodontic treatment was carried out to deal with the crowding which lasted for about 12 months which included nonextraction approach and maxillary expansion using Hyrax appliance. She was instructed to maintain at best during the orthodontic phase of the treatment. The decision was made to impact the maxilla at a Le Fort I level and advance the mandible via bilateral sagittal split osteotomy. Frequent consultations with psychiatrist were established during presurgical orthodontics, and an advice was given to perform surgery during the maintenance phase. Psychiatrist prescribed 500 mg phenytoin 1 hour before surgery. She was
FIGURE 2. Lateral cephalometry of the patient (A) before and (B) after treatment.
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FIGURE 3. Pretreatment and posttreatment tracing superimpositions.
ordered to discontinue lithium intake 3 days before surgery, considering a half life of the prescribed drug. During surgery, rigid internal fixation was used to stabilize the osteotomy segments.
TREATMENT RESULTS The radiographic superimposition showed that, as planned, the maxilla moved superiorly, the mandible advanced, and the chin projection improved greatly by advancement genioplasty (Fig. 3). After surgery, cephlosporine, acetaminophen, antihistamine, and fursulfate were prescribed for the patient. She restarted lithium with close control about 1 week after surgery. After surgery, the patient showed manifestations of depression, which rapidly changed to happiness as a result of the achieved improvement in the facial appearance. After 6 months of postsurgical orthodontics (minimum duration), braces were removed, and patient was referred to a periodontist to monitor her periodontal status, considering the side effects of drugs and also to replace the previously extracted molar with an implant-based prosthesis (Fig. 3).
DISCUSSION Presurgical Orthodontics and Considerations Considering the approved guidelines for bipolar patients, it is recommended that before initiation of any type of intervention, updated information on history of medication regimen, level of patient’s cooperation, and overall psychiatric profile should be obtained in consultation with the patient’s psychiatrist. All psychiatric illnesses conditions should be accurately understood before any treatment should be planned, and this may involve seeking guidance from the patient’s psychiatrist.20 To date, many studies have investigated the prevalence and pronounced clinical feature of common psychological disorders like depression and body dismorphic disorder among orthognathic surgical patients.21 There is always a possibility that the observed dentofacial deformity is the main underlying reason of generated psychological disorder. It is very crucial for patients with psychological disorders to clarify the individualized cost and benefits of receiving any optional surgery. It might necessitate receiving multiple steps of consultation with experts on anticipated results, particularly if the surgery would directly impact an aspect that could change the psychological profile of the patient, interactively. Orthognathic surgery could be considered as an optional surgery for a patient suffering bipolar disorder. However, considering the #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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possible impact of the surgical results on facial appearance and consequently on overall psychological status of patients, it needs extra time for clinicians to anticipate advantages and disadvantages of orthognathic surgery for bipolar patients. Caution must be taken about integrity of realistic patients’ and surgeons’ expectations from the surgical procedure.21 We have used supplementary records of previous patients with same dentofacial deformity to help the patient understand her problem and her treatment process. A multidisciplinary team, including surgeon, psychiatrist, psychologist, orthodontist, and general dentist should provide a comprehensive treatment plan. The overall aim of managing these patients must contain relief of malocclusion, maintenance of oral health, and prevent further functional impairment of the patient. Because of the psychiatric status of these patients, orthodontic treatment should be carried out in minimum duration. In most of these conditions, it seems that surgical intervention must be avoided unless distinct soft tissue improvement or serious functional problems are encountered, including condylar ankylosis and restricted jaw functions. However, nonspecific and vague expectation of possible facial improvement by orthognathic surgery must not be considered valid enough to select this treatment regimen for this group of patients. With regard to intraoral oral conditions, bipolar patients suffer from dry mouth due to the antidepressant medication.22 Xerostomia (73%) and generalized stomatitis are common complications of patients under lithium therapy.22 Although the xerostomia following the mood stabilizer drugs is thought to play a role in increased cervical caries rate, this relationship is complex.22 It is also reported that increased usage of saliva-stimulating candies and sweet nutrients by patients as oral lubricants also might worsen the situation. Hypersalivation after lithium therapy also has been reported.23 Preventive dental education for these patients and their families, including reinforcement of daily oral hygiene activities, regular usage of chlorhexidinegluconate mouth rinse to decrease gingival inflammation, and periodic fluoride therapy to reduce the incidence of caries, is the mainstay of orthodontic treatment of these patients.24 In addition, protocol for dry mouth, including commercially available saliva substitutes, sugar-free chewing gums, and other stimulus, must be considered.24 It must be considered that during the manic stage, many patients exhibit abraded oral musoca in combination with various degrees of cervical tooth abrasion caused by unconscious harsh usage of toothbrushes and other oral health aids.25 In contrast, during depression phase, decreased level of oral hygiene may be associated with distinct increase in incidence of dental caries and potential periodontal problems.26 Oral hygiene is critical for successful completion of orthodontic treatment. Visiting patients on their manic episodes, except simple psychiatric considerations to control their restlessness on dental units, need no further interventions.27 However, decreasing the duration of presurgical orthodontics is recommended. Mood switching phenomena for bipolar patients is multifactorial and highly unpredictable, usually based on individual disease patterns.28 If the patient goes through a depression mood, it would be difficult to keeping the regular follow-up appointments. Close cooperation of the patient’s family plays an important role during this phase of bipolarvals. Regular consultation with patient psychiatrist may also be needed until stable psychiatric status could be obtained.20 Gingival overgrowth is another manifestation of using of anticonvulsant drugs (Valproic), which is used routinely during acute manic and maintenance phases.29 In extreme severe conditions, hyperplasia may impede the orthodontic tooth movements and slow the speed of overall treatment. Gingivectomy is not recommended during active treatment, and in extreme conditions, contacting the #
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Surgical Considerations in Bipolar Patients
patient’s psychiatrist to discuss alternative medication is recommended.30 Fortunately, no special medications are required during orthodontic treatments of patients who suffer from bipolar disorder. However, in some occasions, local anesthesia might be used to insert or remove temporary anchorage devices, extractions, or special canine exposure procedures. Various psychotropic medications block the a-adrenergic receptors that are responsible for vasoconstriction in smooth muscles and thereby decrease the vasoconstrictor effect of epinephrine in local anesthesia.31 Shortened duration of local anesthesia and hypotension with secondary tachycardia might be the consequences of interactions with these psychotropic agents.31 Particularly for the patients in the acute depressive phase, who temporarily receive TCAs, sedative medications must be avoided. The potential interaction of these 2 group drugs may cause severe respiratory depression.32 The use of local anesthesia with epinephrine is controversial in this specific phase because of the possibility of develop severe hypertensive crisis; however, many clinicians consider this danger not clinically relevant enough to make a recommendation. However, care must be taken to at least avoid intravascular injection of the epinephrinecontaining local anesthesia.33 Considering the wide range of medications used at different phases of bipolar disorder, only some considerations with lithium and monoamino oxidase are available. Major adverse interactions between lithium and dental medications are not common.26 However, the use of nonsteroidal anti-inflammatory drugs (NSAIDS) similar to some antibiotics like metronidazole and tetracycline may slow the rate of the renal clearance of lithium and consequently, rising the plasma level of the lithium by 40% to 60%; which could lead to toxic effects.23,34 In addition, if the patient is taking selective serotonin reuptake inhibitors at acute depressive phase, risk of intestinal bleeding should have been taken into account at concomitant prescription of NSAIDS.35 On the other hand, the literature indicates that prolonged usage of NSAIDS might decrease the rate of orthodontic tooth movement. Therefore, for bipolar patients under orthodontic treatment, prolonged prescription of NSADIS, such as ibuprofen, is not recommended; however, short-term use of NSAIDS may not pose a problem in this regard.36 Patient’s receiving monoamino oxidase as an antidepressant agent in acute depressive phase should avoid taking sympathomimetic medication and also avoid epinephrine injection.37 Repeated preoperative psychiatrist evaluation before the surgery is recommended to prepare the patient before this intervention.
Orthognathic Surgical Considerations Two main risks should be dealt within patients using psychotropic drugs who undergo elective surgery: first, increased risk through psychiatric drug direct effect and its interaction with anesthesia. Second, the impacts of the temporary withdraw of psychotropic drug and its impact on the patients’ deterioration.38 A stable psychiatric status of the patient is essential before surgical intervention.32 Current psychotropic medication regimen is the main deterministic factor that must be considered to select proper type of anesthesia and type of fixation during surgery.38 Regarding the possible severity grades of reported psychotropic drug interaction, interdisciplinary consultation is highly recommended. The best possible stage for surgery on bipolar patients seems to be during maintenance phase, in which there would be no serious concern about the psychiatric status of the patient. If the patient is on the lithium regimen, lithium discontinuation is recommended.37 Direct effects of lithium might cause hemodynamic instability which is a hazardous risk because of interactions with sodium and potassium metabolism.38 Long time fasting and large fluid loading (needed because of anesthetic technique) which lead to
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Tehranchi et al
The Journal of Craniofacial Surgery
acute hypernatremia, necessitates closer monitoring and the possibility of utilizing different anesthetic strategy to avoid this classical complication of chronic lithium therapy.39 Lithium can be discontinued at once because no withdrawal symptoms occur. It is recommended to stop usage of lithium 72 hours before surgery.40,41 Decreasing the lithium level of blood should be done best by perioperative administration of sodium-containing intravenous fluids, not by stimulation of urine output with thiazide diuretics.42 This drug reduces the clearance of lithium and has a reverse effect which can result in toxicity.43 Close electrocardiography monitoring should be done to monitor cardiac abnormalities secondary to lithium toxicity. Declined level of anesthetic agents may be required because of the association of sedative medications with lithium.43 The recommended protocol for patients under antidepressant medication who are undergoing surgical procedure is mostly discontinuing the drug (except selective serotonin reuptake inhibitors) because of possible interactions with the anesthetic agents.38 Another possible drug regimen of bipolar patients at maintenance phase is antipsychotic drugs. The second generation of these drugs (olanzapine, quetiapine, risperidone, zeiprasidone, aripiprazole, and asenapine) decrease the extrapyramidal effects and cardiac changes at electrocardiograph monitoring, which can result in other medical complications.38 Hypotension is a reported hazardous side effect of antipsychotics in combination with many halogenated inhaled anesthetics. These possible hazardous side effects can be easily prevented with the aid of modern anesthetic agents. Considering available evidence and guidelines, it is not recommended to discontinue the first-generation antipsychotics for an elective surgery. However, preoperative electrocardiography should be evaluated considering the side effects of these antipsychotics (eg, prolonged QTc intervals).
Postsurgical Orthodontics and Considerations Orthognathic surgery is a complex process which results in changes in the appearance and functions of the dentofacial structures, including respiration, swallowing, speech, and mastication.38 Adequate presurgical preparation is especially important in bipolar patients.44 Psychological disorders may flare during the postoperative period, and sudden discontinuation of psychiatric medication for a sustained period of time adds to the risk of psychiatric disorders relapse. The unexpected nature of mood swings, which can easily be triggered by a surgical procedure, highlights the importance of case selection and monitoring through the whole process. Active role of psychiatrists in all treatment phases, particularly postsurgical phase is necessary.45,46 The management of possible mood swing depends on its severity could range from a simple behavioral management or altering the mood stabilizer. It is usual for patients to suffer from some depression after orthognathic surgery.43 To date, no study evaluate the impact of orthodontic or orthognathic surgery on psychological profile of patient with serious mental illness. It is important in bipolar patients to restart lithium with close monitoring within 1 week when patients return to the normal diet and are hemodynamically stable.38 Although it has been reported in the literature that psychological well-being of orthognathic patients does not alter with fixation type (wire or rigid), considering other advantages related to oral function and social interaction,47 the use of rigid internal fixation with minimal intermaxillary elastics should be considered to minimize postoperative stress and anxiety. Further studies are needed to optimize every single step of orthognathic surgery for patients with psychological disorders. Ultimate success of surgical treatment modality should be assessed by both occlusal function and morphological improvement, and also changes in the psychosocial wellbeing of affected patients.44
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ACKNOWLEDGMENTS The authors thank Dr. Ashraf Ayoub and Dr. Rebecca Crawford for technical help and writing assistance in this article.
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