Elsevier

Journal of Affective Disorders

Volume 223, 1 December 2017, Pages 184-193
Journal of Affective Disorders

Research paper
Oral health impacts of medications used to treat mental illness

https://doi.org/10.1016/j.jad.2017.07.037Get rights and content

Highlights

  • Xerostomia was the most prevalent oral side effect of common psychotropic drugs.

  • Side effects of common psychotropic drugs can increase the risk of dental diseases.

  • To manage side effects, physicians should work with dental practitioners, pharmacists, and other allied health professionals.

  • Clinicians should also take into account the side-effect profiles when choosing an agent.

  • Atypical antipsychotics and mood stabilisers agents have less oral side effects than older alternatives.

Abstract

Background

Many psychotropic medications affect oral health. This review identified oral side effects for antidepressant, antipsychotic, anticonvulsant, antianxiety and sedative drugs that are recommended in Australia for the management of common mental illnesses and provides recommendations to manage these side-effects.

Methods

The Australian Therapeutic Guidelines and the Australian Medicines Handbook were searched for medications used to treat common mental health conditions. For each medication, the generic name, class, and drug company reported side-effects were extracted from the online Monthly Index of Medical Specialties (eMIMs) and UpToDate databases. Meyler's Side Effect of Drugs Encyclopaedia was used to identify additional oral adverse reactions to these medications.

Results

Fifty-seven drugs were identified: 23 antidepressants, 22 antipsychotics or mood stabilisers, and 12 anxiolytic or sedative medications. Xerostomia (91%) the most commonly reported side effect among all classes of medications of the 28 identified symptoms. Other commonly reported adverse effects included dysguesia (65%) for antidepressants, and tardive dyskinesia (94%) or increased salivation (78%) for antipsychotic medications.

Conclusions

While xerostomia has often been reported as a common adverse effect of psychotropic drugs, this review has identified additional side effects including dysguesia from antidepressants and tardive dyskinesia and increased salivation from antipsychotics. Clinicians should consider oral consequences of psychotropic medication in addition to other side-effects when prescribing. For antidepressants, this would mean choosing duloxetine, agomelatine and any of the serotonin re-uptake inhibitors except sertraline. In the case of antipsychotics and mood stabilisers, atypical agents have less oral side effects than older alternatives.

Introduction

Mental health disorders affect 45% of Australians at some point in their lives, and in 20%, symptoms last for a year or longer (Australian Bureau of Statistics, 2007). The most prevalent disorders include depressive episodes, social phobia and post-traumatic stress disorder (Australian Bureau of Statistics, 2007).

Pharmacotherapy is an important part of management. In depressive disorders, antidepressants including selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) are first-line treatment options; and tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) second-line treatment options (Health Communication Network, 2016a, Therapeutic Guidelines Limited, 2013bc). Dependent upon the anxiety disorder (including general anxiety, posttraumatic stress, obsessive or panic disorders), antidepressants, antipsychotics and benzodiazepines are typically used in either the short or long term (Health Communication Network, 2016a, Therapeutic Guidelines Limited, 2013b). Rarer conditions such as schizophrenia or bipolar disorders are managed with single or combination therapy of antidepressants, antipsychotics and anticonvulsants as mood stabilisers.

The oral health of people with mental health conditions is poorer than the general population, with higher rates of decayed, missing and filled teeth, dry mouth and soft tissue lesions (Kisely et al., 2011, Kisely et al., 2016, Longley and Doyle, 2002). This disparity may be due to compounding issues of homelessness, poorer diet and sweet drink consumption, tobacco smoking, disabilities, dental phobias and barriers to accessing dental care (Ford et al., 2014, Longley and Doyle, 2002, Prince et al., 2007). However, side effects from psychotropic medication also contribute. For instance, the impact of anticholinergic drugs on saliva production has been well documented, and dry mouth as a result of antidepressant and antipsychotic drugs has been reported (Rafaelsen et al., 1981, Scully, 2003, Stiefel et al., 1990, Turner and Ship, 2007). A reduction in saliva due to pharmacological management of mental health, places oral health at risk. This is due to the critical protective role played by saliva for the teeth and soft tissues of the mouth (Scully, 2003). We therefore reviewed the reported oral side effects of psychotropic drugs recommended for common mental health conditions in Australia.

Section snippets

Methods

The Australian Therapeutic Guidelines and the Australian Medicines Handbook were searched for drugs used in the treatment of common mental health conditions including depression, anxiety, panic, post-traumatic stress, obsessive compulsive, bulimia, insomnia, delirium, schizophrenia and bipolar disorders (Table 1). For these common mental health conditions, recommended pharmacological treatment includes antidepressants, antipsychotics, anticonvulsant, anxiolytic and sedative drugs (Table 1) (

Results

Fifty-seven drugs used in the treatment of mental health were identified from the Australian Medicines Handbook and The Australian Therapeutic Guidelines (Table 1) (Health Communication Network, 2016a, Therapeutic Guidelines Limited, 2013b). Of these, 23 drugs were antidepressants (Table 2), 22 antipsychotic or anticonvulsant drugs (Table 3) and 12 were for the treatment of anxiety or sleep disorders (anxiolytic and sedative medications) (Table 4). Within the antidepressants, 2 were monoamine

Oral side effects of antidepressants

Table 2 lists the 19 different reported oral side effects of antidepressant drugs. Almost all (96%) of the medications caused xerostomia and approximately two-thirds (65%) dysguesia. Other side effects in order of frequency (of antidepressant drugs) were increased salivation, stomatitis, dysphagia, bruxism, glossitis, tardive dyskinesia, hairy tongue, salivary gland enlargement, tongue oedema, tooth disease, gingivitis, halitosis, ulcers, periodontal disease, erythema multiforme, sinusitis, jaw

Oral side effects of antipsychotics and anticonvulsants

Table 3 lists the 25 different reported oral side effects of antipsychotic drugs. All antipsychotic and anticonvulsant drugs reported xerostomia as an oral side effect. Commonly reported adverse effects included tardive dyskinesia (94%) or increased salivation (78%) for antipsychotic medications. The reported side effects of antipsychotics and anticonvulsants comprised of (from most to least frequent), xerostomia, tardive dyskinesia, increased salivation, dysphagia, tongue odema, sinusitis,

Oral side effects of anxiolytic and sedative drugs

As for the anxiolytic drugs, xerostomia was the most common reported side effect (75%) followed by increased salivation (56%) (Table 4). Less common side effects included dysguesia, Stevens-Johnson syndrome, halitosis, sinusitis, hairy tongue, gastroesophageal reflux, ulcers, tardive dyskinesia, dysphagia, tongue odema and dental caries. Oxazepam had no oral side effects. In terms of side-effect frequency, melatonin and shorter acting benzodiazepines had more side effects than longer-acting

Discussion

The impact of dental disease on systemic medical morbidity is often overlooked. Oral health has previously been associated with systemic diseases such as diabetes, cardiovascular disease, and bacterial pneumonia (Awano et al., 2008, Azarpazhooh and Leake, 2006, Lamster et al., 2008, et al., 2004, Seymour et al., 2007). The association between oral and general health is complex. In addition to traditional risk-factors such as smoking, obesity and high blood pressure, oral infections represent a

Conclusion

This study has described the reported oral side effects of drugs taken to treat common mental health conditions. Xerostomia was the most prevalent reported oral side effect of these drugs, followed by excessive salivation (paradoxically), dysguesia and tardive dyskinesia. Side effects of common psychotropic drugs can increase the risk of dental diseases and therefore preventive oral health measures and multidisciplinary care is required. Physicians should work with dental practitioners,

Acknowledgments

None.

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