[Mental disorders in the dental practice. Substance use disorders]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Middelgerelateerde stoornissen.

When addictive substances are used excessively and a person continues to use them despite the fact this causes problems, this is called substance use disorder. Despite the large scale of the problem, it occurs largely invisibly. However, it has many negative consequences for physical and psychological health, the surroundings (including family, friends, work) and society. Genetic and environmental factors play a role in the origin and continuation of substance use disorders. In many cases, these disorders affect oral health, personal care and treatability. Oral healthcare professionals can play an important role in identifying substance use disorders, in encouraging those with problematic substance use to seek professional help and as an essential step in treatment and recovery.

[Mental disorders in the dental practice. Autism spectrum disorder]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Autismespectrumstoornis.

Autism spectrum disorder is a developmental disorder with a prevalence of about 1% of the population. This disorder, characterised by limitations in the domain of social communication, interaction, flexibility and processing stimuli, often requires additional attention in the dental practice. The disorder can have an effect on both general health and oral health as a result of unusual eating habits, problems with oral hygiene, the use of psychotropic medications or a vitamin D deficiency. The treatment of patients with an autism spectrum disorder generally also requires more time and patience due to the non-typical communication and interaction. Analysing the sensitivities and fears of a specific patient with autism spectrum disorder, if necessary in consultation with parents of carers, is also recommended.

[Mental disorders in the dental practice. Patients with body dysmorphic disorder]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Patiënten met een morfodysfore stoornis.

Oral healthcare professionals are frequently consulted by patients who are dissatisfied with their teeth and/or facial looks. Sometimes, this dissatisfaction takes a pathological form. When someone is preoccupied with a (supposed) abnormality barely or not visible to others, performs certain actions in response to the concerns about their appearance and experiences significant suffering, this may be a case of body dysmorphic disorder. Its prevalence is 0.7-2.4% in the general population, but significantly higher in clinics where cosmetic or orthognathic procedures are performed (10-15%). Procedures aimed at improving the abnormality experienced by the patient rarely lead to a reduction of the symptoms, but more often result in more dissatisfaction and complaints towards the practitioner. It is difficult for practitioners to recognise this condition. An overview of characteristics, co-morbidity and consequences of body dysmorphic disorder for oral health and treatment will result in increased awareness of this condition among oral care providers.

[Mental disorders in a dental practice. Patients with mental disorders in the dental practice - an introduction]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Patiënten met psychische aandoeningen in de tandartspraktijk ­ een inleiding.

Given the high prevalence of mental disorders and the consequences that sometimes arise from this for oral health or the treatability of the patient, it is important for oral care professionals to have some basic knowledge of these disorders. This introductory article examines mental disorders in general, their classification according to the most widely used manual of mental disorders (the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5) and some relevant differences in classification and designation from the previous edition of the DSM.

[Administration of intravenous sedation with midazolam by dentists is unsafe]. / Toediening van intraveneuze sedatie met midazolam door tandarts is onveilig.

In the December issue of the Nederlands Tijdschrift voor Tandheelkunde (Dutch Journal of Dentistry) in 2014, an article was devoted to the use of light sedation with midazolam by dentists. A number of dentists who are active in the area of Special Dentistry (anxiety management, care of the disabled) and a anesthesiologist offer a response to the article and argue that the administration of intravenous sedation with midazolam by dentists is unsafe.

[Patients with unusual requests for extractions 2. Mental incompetency and psycho-pathologic causes]. / Patiënten met ongewone extractiewensen 2. Wilsonbekwaamheid en psychopathologische oorzaken.

If there is no indication for tooth removal purely based on dental criteria, but the patient requests for removal due to fear of dental treatment, or because of a mental disorder such as posttraumatic stress disorder, a somatoform pain disorder or a disorder of body image perception, then the question is whether the patient is mentally competent to make this decision. In case of a tooth removal request on psychopathologic basis, a dentist has to refuse to carry out such treatment, but he should make an effort to help or guide the patient in some other way.

[Patients with unusual requests for extractions 1. professional standard versus patient's autonomy]. / Patiënten met ongewone extractiewensen 1. Professionele standaard versus autonomie van patiënten.

Assertive patients will, in the future, more readily appear with their own diagnosis. As a result, dentists will more often be confronted with sometimes rather unusual requests from patients. An extreme request from a patient is the removal of (all) teeth. The central issue in this article is how to deal with such a request. The conclusion is that the patient's autonomy is limited by the professional standards of the dentist and the patient's capacity to assess in a reasonable way what is in his own best interests.

[A dissociative patient]. / Een dissociërende patiënt.

A 45-year-old woman attended a centre for special dental care. Initially, it seemed that the patient suffered from an extreme form of dental anxiety. However, the fact that she displayed 'dissociations' suggested that she had a severe psychiatric disorder, in this case Dissociative Identity Disorder. The key feature of this condition is a dysfunction of the normal integrative functions of identity, memory and consciousness. In such instances it is recommended to contact a psychologist or psychiatrist and the referring care provider to consider the consequences of the psychiatric condition regarding informed consent, treatment plan and actual treatment. Because it was not likely that the patient would respond to an intervention specifically aimed to reduce anxiety in the dental setting, dental treatment under general anesthesia was the best suited option.

[Risks of dental fear reduction treatments]. / De risico's op het mislukken van een angstbehandeling.

In dentistry, estimations of the risk of failure of treatments focused on dental fear reduction are particularly high (about 60%). Research data on this subject are lacking. Failure has been defined as a treatment whose aim, sufficient reduction of fear to make possible treatment in a general dental practice, has not been achieved. Nine different types of risk may be the cause of a treatment failure: insufficient motivation, fear greater than the capacity to cope with it, co-morbidity, trouble with entering into a patient-care provider relation, inaccurate treatment indication or treatment strategy, patient too dependent on care provider, treatment insufficiently fulfilling demand, damage to the patient-care provider relation, and accident during treatment.

[Post-academic dental specialties 12. Post-graduate specialization in 'dealing with fear of the dentist']. / Beroepsdifferentiatie in de tandheelkunde 12. De differentiatieopleiding 'tandarts-angstbegeleiding'.

As a result of the recognized need for dentists with a special expertise in the field of managing and treating patients who are difficult to treat especially because they are fearful, a post-graduate programme was established, in 2001, in 'dealing with fear of dentists.' This 3-year programme of study makes it possible for dentists, both working within and outside of departments of special dental care, to develop knowledge and experience in this field. The intention behind this initiative is to contribute to the quality of care provided to patients who avoid treatment out of fear. A brief summary of the programme's target group and academic goals, as well as its organization and contents are provided.

[Post-academic dental specialities 8. Post-academic specialization in dental care for disabled]. / Beroepsdifferentiatie in de tandheelkunde 8. Opleiding tot tandarts-gehandicaptenzorg.

The dental treatment of people with a mental and/or physical disability often entails a variety of related problems and requires extra expertise and competencies on the part of the dentist. If treatment in an ordinary practice is not (or is no longer) possible, the patient can be referred to a centre for special care dentistry or to dental practices in institutions for the mentally disabled. In the Netherlands, a three year postgraduate programme in dentistry for the disabled was established in 2004, the purpose of which is to improve the availability and quality of dental care for the disabled.

[Post-academic specialties 9. Dental care of disabled children living at home]. / Beroepsdifferentiatie in de tandheelkunde 9. Problemen in de mondzorg voor kinderen met een ernstige verstandelijke beperking.

The aim of this study was to identify possible problem areas regarding preventive selfcare and dental care for severely mentally retarded children living at home. The sample test comprised parents (n = 126) and dentists (n = 40) of children between the ages of 4 and 12 from 7 randomly selected daycare centres in The Netherlands, who were asked to fill out a questionnaire. Of the children 32% were found to receive no dental care at all, while among the children from ethnic minority groups this number exceeded 50%. Of the parents two-thirds indicated that they had encountered problems with daily dental care and 70% reported that their child's oral hygiene was in need of improvement. Of the dentists 25% were dissatisfied with the dental care they provide, and 75% felt that dental care for mentally retarded children needs improving. The results suggest that there is room for improvement in the support of parents of mentally disabled children in maintaining an adequate level of oral hygiene, and that adequate training of dental professionals in serving the needs of people with severe disabilities is wanted.

[Guidelines for the treatment of highly anxious dental patients]. / Behandelstrategieën voor patiënten met pathologische angst.

Treatment of extreme or pathological forms of dental anxiety requires specific skills. This paper is an attempt to formulate a number of treatment strategies, based on the available literature and effectiveness studies. It is suggested that based upon the assessment information three types of problem areas can be identified, namely, 1. a phobia of specific dental procedures or situations; 2. long overdue requiring acute dental treatment; and 3. intrusive or interfering psychiatric symptoms. In this article these problem situations are reviewed and several appropriate treatment options are discussed.