|Year : 2014 | Volume
| Issue : 4 | Page : 330-332
Obsessive compulsive disorder in dental setting
Preetika Chandna1, Nikhil Srivastava2, Vivek Kumar Adlakha1
1 Department of Paedodontics and Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India
2 Department of Preventive Dentistry, Subharti Dental College, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India
|Date of Web Publication||17-Sep-2014|
Subharti Dental College, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Globally, 20% of children and adolescents suffer from a disabling psychologic illness. Among these, Obsessive Compulsive Disorder (OCD) is listed by the World Health Organization (WHO) as one of the 10 most disabling conditions, with prevalence rates of OCD in children ranging between 1 to 3%. Pediatric dentists are in a unique position to diagnose psychological problems in children and adolescents due to their ongoing relationship with children and their parents that starts at a very early age. Timely diagnosis of psychological illness can result in early intervention as well as better patient management for the dentist too. The purpose of this case report is to highlight a case of OCD in an adolescent girl diagnosed in a dental setting.
Keywords: Psychologic disorder, dental obsessive compulsive disorder
|How to cite this article:|
Chandna P, Srivastava N, Adlakha VK. Obsessive compulsive disorder in dental setting
. J Indian Soc Pedod Prev Dent 2014;32:330-2
| Introduction|| |
Globally, 20% of children and adolescents suffer from a disabling psychologic illness.  Among these, obsessive compulsive disorder (OCD) is listed by the World Health Organization as 1 of the 10 most disabling conditions.  The prevalence rates of OCD in children range between 1% and 3%.  OCD has a childhood onset in 80% cases and is the fourth most common childhood psychologic disorder.  Psychologic disorders of childhood and adolescence such as OCD largely remain undiagnosed until significant problems occur later in life related to impaired school or social functioning and early careers. The financial burden on the family of the affected person may also be debilitating. The most evidenced predictor of psychologic disorder in adult life is a psychologic disorder during childhood and adolescence.  The impact of OCD early in life can extend over a lifetime - studies show that there is substantial continuity of psychopathology, from childhood into adulthood. 
Pediatric dentists are involved with prevention, diagnosis, and treatment of dental illness in children from infancy through adolescence. Pediatric dentists are, therefore, in a unique position to diagnose psychological problems in children and adolescents due to their on-going relationship with children and their parents that start at a very early age. The American Academy of Pediatric Dentistry recommended age of first dental examination of a child is 12 months of age or within 6 months of eruption of the first tooth.  Timely diagnosis of psychological illness can result in early intervention as well as better patient management for the dentist too. The purpose of this case report is to highlight the case of behavioral problem in an adolescent girl.
| Case Report|| |
11-year-old girl [Figure 1], reported to the OPD of the Department of Pedodontics and Preventive Dentistry, with the chief complaint of pain in tooth in number 16 and the carious decay in number 75, 36 and 46. Dental treatment proceeded in a planned manner. However, as treatment progressed (after two visits) we observed that Farhana would get agitated if the dental chair were not cleaned in front of her eyes. Reassuring her that the chair was clean did not allay her anxiety. During the treatment, she would close her eyes and appear to be counting silently. Sometimes she wouldn't open her mouth till she was done counting. On completion of dental visit, she would make sure the chair was returned to the proper position (she would do it herself if we did not comply with her wishes). The patient's mother reported that the girl's father showed similar behavior, but they had not visited any doctor for consultation, so the father's diagnosis of OCD was not confirmed.
|Figure 1: An adolescent girl with symptoms of obsessive compulsive disorder|
Click here to view
On talking to her mother, we found out that Farhana had been suffering from some peculiar behavior problems since the last 1½ years. At home too, Farhana arranged all her things in a particular sequence every time she started studying. She would check repeatedly if the windows of her room were closed before she left. She also insisted on counting the number of steps 4 times every time she went up or downstairs. Farhana's mother reported that Farhana counted the steps leading to her classroom in the school as well and was frequently late for school due to the counting and arranging rituals at home. Her school marks were declining due to all her time-consuming counting and checking behavior. On further questioning, we found that her behavior met the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Text Revision (DSM IV-TR)  criteria for OCD with her obsessions, compulsions and impairment of routine life [Table 1]. The differential diagnosis of OCD includes schizophrenia, tic disorders, trichotillomania, anorexia nervosa, generalized anxiety disorder (GAD), and autism spectrum disorders.  The behavior problem was explained to Farhana's mother, and Farhana is currently undergoing psychologic behavior counseling for the same.
| Discussion|| |
As per the DSM IV-TR, OCD is characterized by obsessions and compulsions.  OCD is a type of anxiety disorder.  Children and adolescents with OCD experience recurrent, uncontrollable obsessions, and compulsions that are time-consuming (taking up more than 1 h a day).  Obsessions are persistent ideas, thoughts, images, impulses that are intrusive or inappropriate.  These are characterized by being irrational, excessive, and unrealistic.  Common obsessions include thoughts about contamination, germs, persistent doubts, e.g., door locks, gas knobs, concerns of extreme perfection and order and fears that one may injure someone. These obsessions lead to significant anxiety and distress.  Farhana's obsessions included extreme concern and agitation about cleanliness of the dental chair and thoughts about symmetry and order of the dental chair and books at home.
Children and adolescents with OCD go to considerable lengths to decrease this anxiety through actions called "compulsions." Compulsions are repetitive behaviors or mental acts performed in response to an obsession.  Common compulsions include excessive hand washing and bathing, checking, counting over and over, repeating, doing things in a certain order, arranging to achieve symmetry, and exactness and hoarding.  Farhana's compulsions include counting steps, checking cleanliness of the dental chair and arranging objects such as dental chair in our clinic and books at home. Since compulsions are repetitive behaviors or mental activities, Farhana's compulsions in the dental operatory became evident after two visits when a repetitive pattern began to be observed, and treatment became hampered due to time taken to perform compulsions leading to suspicion of abnormal behavior characterized by OCD.
Obsessive compulsive disorder can begin at any time from preschool to adulthood.  The mean age of onset is 9-12 years.  In our case, the affected child, Farhana, was 11-year-old. Prevalence of OCD in children and adolescents ranges from 1% to 4%.  OCD shows a genetic basis  and the patient's father reportedly experienced similar symptoms. However, lack of confirmed diagnosis in the father makes the etiologic genetic basis questionable. One-third to two-thirds of children and adolescents with OCD continue to fit the criteria for the disorder 2-14 years later too.  A "difficult to treat" child or adolescent in the dental office may very well be an ill-child; an informed pediatric dentist will know the difference. OCD is differentiated from tic disorders, trichotillomania and anorexia nervosa as in these disorders, obsessions are limited to a specific obsession only (e.g., hair pulling in trichotillomania); while in OCD, obsessions and compulsions range over multiple thoughts and behaviors.  OCD is distinguishes from GAD as the obsessions in OCD are much more intrusive and socially unacceptable.  Pediatric schizophrenia is extremely rare unlike OCD in childhood and adolescence. Autism spectrum disorders are distinguished from OCD since they are accompanied by developmental delay. 
A few points that may alert a pediatric dentist to early signs of OCD are as follows:
- Insistence by the child or adolescent patient on doing things in a particular way.
- Anxiousness or agitation seen in the patient if his/her wishes not followed exactly.
- Persistently late patient - OCD rituals are time-consuming and may lead to patient being delayed for a dental appointment due to performance of rituals such as counting steps or checking locks.
- Patient washing hands excessively, repeating, counting or checking excessively.
| Summary|| |
Pediatric dentists develop a relationship with parents of children being treated. With a little knowledge of psychologic illness, many at-risk children may be identified and brought into psychologic therapy to prevent lifelong suffering.
| References|| |
|1.||WHO. The World Health Report 2000 - Health Systems. Improving Performance. Geneva: World Health Organization; 2000. |
|2.||Murray CJ, Lopez AD. Global Burden of Disease and Injury Series. Cambridge, Mass: Harvard University Press; 1996. |
|3.||Merlo LJ, Storch EA. Obsessive-compulsive disorder: Tools for recognizing its many expressions. J Fam Pract 2006;55:217-22. |
|4.||Sloman GM, Gallant J, Storch EA. A school-based treatment model for pediatric obsessive-compulsive disorder. Child Psychiatry Hum Dev 2007;38:303-19. |
|5.||Fryers T, Brugha T. Childhood determinants of adult psychiatric disorder. Clin Pract Epidemiol Ment Health 2013;9:1-50. |
|6.||Reef J, van Meurs I, Verhulst FC, van der Ende J. Children's problems predict adults' DSM-IV disorders across 24 years. J Am Acad Child Adolesc Psychiatry 2010;49:1117-24. |
|7.||American Academy of Pediatric Dentistry. Policy on the dental home. Pediatr Dent 2013-14;35:13-4. |
|8.||American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Text Rev. Washington, DC: American Psychiatric Association; 2000. |
|9.||Lewin AB, Piacentini J. Evidence-based assessment of child obsessive compulsive disorder: Recommendations for clinical practice and treatment research. Child Youth Care Forum 2010;39:73-89. |
|10.||Steinberger K, Schuch B. Classification of obsessive-compulsive disorder in childhood and adolescence. Acta Psychiatr Scand 2002;106:97-102. |
|11.||Cameron CL. Obsessive-compulsive disorder in children and adolescents. J Psychiatr Ment Health Nurs 2007;14:696-704. |