Pediatric patients diagnosed with mental disorders have limitations in either both intellectual functioning and adaptive behavior. A good oral health requires a manual dexterity, the motivation of the patient and his cooperation. These three criteria are lacking in pediatric patients with mental disorders.            

Actually, there is a high prevalence of children with psychological illnesses. For example, two out of hundred newborns have mental disorders [1]. This category of children is characterized by a lack of awareness of the importance of an oral hygiene practice. Compared with the typically developing population, these children have a poor oral health, which leads to pain, eating difficulties, sleeping troubles and a decrease in the self-estimation.

Psychotropic drugs are used to manage these psychiatric disorders. In USA, it was estimated that 7 to 10% of children are treated with psychotropic drugs. They are able to modify the behavior, mental state and psychic activity of the patient [2].

There are six categories of psychotropic drugs, which are frequently prescribed, such as anxiolytics, neuroleptics, hypnotics, mood stabilizers, antidepressants and psychostimulants [3].

Unfortunately, most of these drugs have side effects like xerostomia, dysgeusia, dyskinesia, bruxism and hyper salivation, which put the oral health at risk.

The aims of this study were to determine the side effects of psychotropic drugs on the oral health of pediatric patients with psychiatric disorders, to determine their care needs and to describe mechanisms of action of psychotropic.

Study design and setting

A case control study was carried out in the child psychiatry department in Hedi Chaker University Hospital in Sfax and in a primary school, in a period of 4 months between December 2018 and March 2019 using paper-pen versions of a questionnaire.

Participants

One hundred twenty-two children aged between 4 and 12 years old participated in the study. These children were devised into two groups: the group of cases was made of 61 children with psychiatric disorders who were followed up in the child psychiatry department in Hedi Chaker University Hospital in Sfax. The control group was also made of 61 children, who were chosen randomly, in a good general health and who were attending a primary school in Sfax.

Inclusion criteria

Case group: Children with psychiatric disorders taking psychotropic drugs for at least 2 months.

Control group: Children in a good general health.

Non-inclusion criteria

Case group:

• Children whose parents refused their participation in the survey
• Children who were aged more than twelve years old or less than four
• Children who were not on psychotropic treatment
• Children whose duration of treatment was less than 2 months

Control group: children with general pathology or under treatment.

Informed consent of the parents and school authorities were obtained before the subjects were included in the study.

Variables

The mean decayed, missing and filled teeth (dmft/ DMFT) index is the sum of the number of Decayed, Missing due to caries, and Filled teeth divided by the sum of the population.

The prevalence of caries is defined as the sum of decayed teeth divided by the sum of the population.

Oral hygiene was assessed basing on plaque, tartar and bleeding indexes as well as brushing frequencies.

Plaque Index:

0: no plaque

1: plaque covering less than 1/3 of the coronary surface

2: plaque covering between 1/3 and 2/3 of the coronary surface

3: plaque covering more than 2/3 of the coronary surface

Bleeding Index:

0: no bleeding

1: bleeding on probing

2: bleeding on brushing

3: spontaneous bleeding

Scale Index:

0: no tartar,

1: supragingival tartar on 1/3 of the coronal surface,

2: supragingival tartar on 1/3 to 2/3 of the coronal surface or tartar under gingiva in discontinuous bands,

3: supragingival calculus over more than 2/3 of the coronal surface or calculus under gingiva in continuous bands.

All symptoms observed in the oral cavity were useful to determine the oral side effects of psychotropic drugs.

Data sources/ measurement

The data collection instrument was a questionnaire, which was elaborated to obtain biographic and psychiatric illnesses data such as gender, age, socioeconomic background, types of psychiatric pathologies and categories of psychotropic drugs.

Oral examination was carried out by one examiner using sterile dental mouth mirror. For the case group, the dental examination was done in the Stomatology Department in Hedi Chaker University Hospital. For the control group, children were made to sit on a comfortable chair in a well-illuminated airy room in the primary school.

Oral hygiene, habits and dental history were collected. The number of decayed, missing and filled primary and permanent teeth: dmft+ DMFT, periodontal diseases, malocclusions, treatment needs were collected. The prevalence of caries was calculated. The side effects of psychotropic drugs for the case group were noted and behavior during clinical examination was assessed subjectively [4].

Statistical analysis

Data were entered into Excel 2007 and analyzed using IBM SPSS STATISTIC 20 (Statistical Package for Social Science) software. The differences between the groups were analyzed with t-test and Chi-square test.

The differences were considered significant at p < 0.05. To control the quality of data, all the results were checked before final data entry.

For the case group, there were 48 males (78.7%) and 13 females (21.3%) aged between 4 and 12 years with a sex ratio equal to 3.69. For the control group, there were 37 males (60.6%) and 24 females (39.3%) with a sex ratio equal to 1.54. There was a significant difference between the two groups regarding gender (p=0.03).

Parents of the cases (57.4%) and 50.8% of the controls had a low socio-economic background. There was no statistically significant difference between the two groups regarding socio-economic background (p=0.169).

Autism was the most observed pathology with a population of 23 children (37.7%), followed by attention deficit/hyperactivity disorders (ADHD) with a population of 20 children (32.8%). Epilepsy was present in seven children (11.5%), four children had depressive disorder (6.5%) and four children had mental retardation (6.5%).

Down Syndrome was the least represented with a number of three children (4.9%).

While the majority of the children with mental disorders could be examined (72.1 %), the clinical examination of nine children was not successful due to their behavioral problems (14.8%), 9.8% of children were hesitant and 3.3% were passive.

For the case group, only 28 children brushed their teeth daily while 50 children of the controls brushed their teeth at least one time per day.

Fifty-four percent of children from the case group had the habit of snacking throughout the day. This percentage was higher than that of the control group (26.22 %) with a significant difference (p=0.02).

For the cases, the prevalence of tooth decay was 49.2 % while that of the controls was 41% with no significant difference (p=0.363) (Table 1).

The mean dmft/ DMFT index of cases was 2.13 while that of controls was 1.21 with a statistically significant difference (p=0.04) (Table 1).

Table 1: Prevalence of tooth decay and mean dmft/ DMFT index

The prevalence of decayed teeth observed for each type of pathology showed a peak of 60% in children with Attention deficit/hyperactivity disorders (ADHD) while children with Down's syndrome did not present any decayed teeth (Table 2).

Table 2 : Prevalence of tooth decay according to the psychological pathology

For the periodontal status evaluation, the results showed that 65.6% of children with mental disorders had gingivitis while that of the control group was 34.4%. There was a significant difference with p=0.000.

Dental treatment for the children with psychiatric disorders must be performed for 30 children (49.18%) and 32 children required orthodontic treatment (52.45%). For the control group, 25 children (41%) required dental treatment and orthodontic treatment must be performed for 38 children (62.3%). There was no significant difference between both groups regarding treatment needs.

To manage mental disorders, 13 psychotropic drugs were used in this sample. These drugs were 1^st generation antipsychotics, 2^nd generation antipsychotics, psychostimulants, antiepileptic, antidepressants and anxiolytics (Table 3).

Table 3 : Distribution of the sample according to the type of psychotropic drugs

Oral health status according to the type of psychotropic drug

Figure 1 illustrated the oral side effects of psychotropic drugs.

Figure 1: oral side effects of psychotropic drugs

42.6% of children had dyskinesia, 39.3% had hyper salivation, 21.3% had bruxism, 21.3% had halitosis, 17 children had dysphagia, 3 children had xerostomia and 2 children had dysgeusia.

For each category of psychotropic drugs, the oral side effects were identified.

Oral side effects of 1^st generation antipsychotics

Only 12 children were on 1^st generation antipsychotics (Neuleptil®, Nozinan®, Sinaprid®). The reported side effects were gingivitis, dyskinesia, tooth decay, hypersalivation, halitosis, bruxism, gum bleeding, dysphagia, gastroesophageal reflux and glossitis (Table 4).

Table 4 : Oral side effects of 1^st generation and 2^nd generation antipsychotics

Oral side effects of 2^nd generation antipsychotics

Among the 61 children, 18 children were on 2^nd generation antipsychotics such as Risperidone®. The most common effects were gingivitis, tooth decay, dyskinesia, hypersalivation, dysphagia, halitosis and bruxism. Gum bleeding, xerostomia and glossitis were also noted (Table 4).

Oral side effects of psychostimulants

Psychostimulants (Ritalin®) were administered to nine children. Gingivitis was present in six children and six children had bruxism. Among these nine children, 55.55% had tooth decay and 44.44% had halitosis. Gastroesophageal reflux, dysphagia, hypersalivation, dyskinesia, gum bleeding and periodontal disease were also noted (Table 5).

Table 5 : Oral side effects of psychostimulants

Oral side effects of thymoregulators

The three mood-stabilizers drugs that were given to nine children were: Dépakine®, Valoxine® and Tegretol®. The most common side effects were hypersalivation, dyskinesia, gingivitis and gastroesophageal reflux. Tooth decay was present in three children. Dysphagia, dysgeusia, halitosis and hypertrophy of the lingual papilla were also noted (Table 6).

Table 6 : Oral side effects of thymoregulators

Oral side effects of antidepressants

Antidepressants such as Sérotyl®, Elavil® and Serval® were administered to three children. For each child, two side effects were identified: dysphagia, hypersalivation, gastroesophageal reflux, gingivitis, gum bleeding and tooth decay (Table 7).

Table 7 : Oral side effects of antidepressants

Among children in the control group, only 6 children had gastroesophageal reflux and 3 children had hypersalivation. No child showed signs of dysgueusia, dysphagia, bruxism and xerostomia (p=0.000).

Although statistically insignificant, children with mental disorders revealed a higher prevalence of tooth decay as compared to controls. This result was consistent with other studies, which reported higher prevalence of tooth decay in these children than controls [5, 6, 7, 8, 9, 10].

This high prevalence of tooth decay could be attributed to their poor oral hygiene and pharmaceutical form in drinkable syrup of psychotropic drugs. The sweet taste and nighttime use of these drugs, and xerostomia induced by medications increase the risk of tooth decay [3, 11].

Children with mental disorders revealed higher mean dmft/ DMFT index with statistically significant difference. This result was lower than the values found in studies carried out in the Netherlands in 2006, in Yemen in 2013 and in Emirates in 2008 [7, 12, 13].

None of the autistics was caries-free compared to children with Down's syndrome. Children with autism prefer soft and sweetened foods and they tend to pouch food inside the mouth instead of swallowing it, thereby increasing the susceptibility to caries.

In this sample and in children with mental disorders, there were more decayed teeth than filled ones. Several authors have shown that there are more missing and decayed teeth but fewer restored teeth in individuals with mental disorders [5, 14, 15]. This can be explained by the socio-economic conditions and the low income of the parents resulting in neglect of oral care, which remains far from being a priority.

In the present study, children with mental disorders have poorer periodontal status than controls, which was in agreement with several previous reports [16, 17, 18, 19, 20, 21, 22, 23, 24]. This can be explained by the fact that these children cannot brush as effectively as their counterparts can. We must not forget the role of psychotropic drugs, used to control the manifestations of various psychiatric diseases, in the appearance of gingival hyperplasia, which promotes the development of anaerobic bacterial flora responsible for gingivitis and periodontitis.

The oral hygiene of the children with mental disorders examined in the present study was rather poor. Many studies have confirmed poor oral hygiene in this category of children compared to the general population with greater proportions of plaque than normal children [25, 26, 27, 28].

This can be explained by the poor hand coordination, which leads to difficulty in maintaining good oral hygiene in children with mental disorders [29]. Another possible explanation is that this category of children is characterized by a lack of awareness of the importance of oral hygiene practices [22]. When tooth brushing is performed by a third part, the lack of cooperation of these children is the major obstacle encountered [22, 30, 31].

In this sample, 42.6% of children had dyskinesia, 39.3% had hypersalivation, and 21.3% had bruxism. Many literature reviews [9, 32, 33, 34] have shown that typical antipsychotics cause the development of dyskinesia and bruxism through a loss of motor control. Indeed, dyskinesia appears in 15 to 20% of patients on antipsychotics.

Psychotropic drugs act on the neurons and more specifically on the neurotransmitters which allow the transmission of the nervous signal and thus the inter-neuronal communication [33]. Similarly, toxic substances such as paraquat have been shown to severely affect biological systems, with long-term implications on organ health and survival [Singh et al., 2025][].

Dopamine is a neurotransmitter that acts mainly in the central nervous system on dopaminergic neurons. It allows the regulation of many functions such as behavior, cognition, motor functions, motivation, pleasure, sleep or memorization. This neurotransmitter is the most targeted by 1st generation antipsychotics, causing a decrease in the intensity of emotions, thus reducing psychotic symptoms. These antipsychotics lead to a blockage of dopamine and in particular the D2 receptors which is at the origin of motor disorders known under the term "extrapyramidal syndrome" characterized by tremors and involuntary disordered movements affecting both the upper and lower limbs, the head, neck and jaw. These untimely movements, in particular of the mandible, cause orofacial pathologies such as bruxism and dysphagia that significantly alter the patient's quality of life [33].

Second generation antipsychotics have been shown to cause stomatitis, glossitis, dysgeusia, dysphagia [35], xerostomia, dyskinesia and hypersalivation associated with Clozapine. On the other hand, they lead to a suppression of bruxism. Indeed, Second generation antipsychotics act on the dopaminergic and serotonergic systems. Their binding profile favors other receptors such as 5-HT serotonin receptors, histamine H1 receptors, noradrenergic receptors and acetylcholine receptors.

The acetylcholine plays an important role in both the central nervous system and the autonomic nervous system, especially in vegetative functions such as salivation. The anticholinergic effect of antipsychotics creates a decrease in the amount of saliva production by blocking muscarinic cholinergic receptors on postganglionic parasympathetic neurons. It would also seem that antipsychotic medications may have an indirect destructive action on the epithelial cells of the glandular acini by causing degenerative axonal damage to nerves with a secreto-trophic destiny. They can also induce dysgeusia by inhibiting the neuronal transmission of taste receptors [33, 36].

According to Chaumartin and al in 2012 [9], antipsychotics can cause or aggravate dysphagia, which is the result of the disturbance of tongue movements caused by the anti-dopaminergic action of antipsychotics on the nigro-striatal pathway [38].

Psychostimulant drugs lead to the deregulation of the dopamine mesocortical pathway and the increase of adrenergic and dopaminergic neurotransmission in the central nervous system [2]. This leads to bruxism during wakefulness and sleep [33], xerostomia, gingivitis, caries lesions and periodontitis [24, 36].

The most reported effects of antidepressants are xerostomia, bruxism, gum bleeding, dysphagia, halitosis, hypersalivation and dyskinesia. Their mechanism of action consists of the presynaptic inhibition of serotonin re-uptake, down regulation of serotonin receptors, and modulation of serotonergic transmission [2].

Thymoregulators cause gingival hypertrophy, tooth decay, periodontal disease, xerostomia, dyskinesia and ulcerations. The notion of stomatitis and hypersalivation has also been reported [37]. These drugs effect the central nervous system mainly at the second messenger level by blocking sodium channels, potentiation of gamma-aminobutyric acid (GABA), modulation of the glutamate release, which is the main excitatory neurotransmitter of the nervous system, neurogenesis, and neuroprotection [2].

All of the ailments described above result in a deterioration of the quality of life of children with mental disorders and a delay in social integration.

It was commonly known that xerostomia is considered to be the most frequent of the adverse effects of psychotropic drugs [32, 34]. Paradoxically, in this sample, hypersalivation also emerged as one of the most common problems. Although commonly associated with clozapine, this study shows that it can occur with a range of other psychotropic drugs.

The high prevalence of tooth decay, gingivitis, hypersalivation, soft tissue lesions ... is due to the association of several factors such as poor eating habits, lack of hygiene, difficulties in accessing care and the pathology itself. Adverse effects of psychotropic drugs have contributed to the onset or worsening of this condition.

Limitations: the main limitation of this present study was the relatively small number of participants involved. For these reasons, the obtained results cannot be generalized to the entire population. A multi centric study would have given more information about the oral health status of children with mental disorders in Tunisia.

This survey made it possible to assess the state of oral health in the population of children with mental disorders and to determine the probable adverse effects of psychotropic drugs on the entire oral cavity.

Patients with mental disorders are vulnerable to any oral pathology due to a lack of hygiene and autonomy, to which are added the side effects of psychotropic drugs. For these reasons, specific therapeutic and preventive strategies should be instituted and focused towards this special population.

Author Contributions

IS, YE and IH designed the research study. IS performed the research. YE, IH, YM and HG provided help and advice during steps of the survey. IS analyzed the data. IS wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

Funding

This research has received no external funding.

Ethics Approval and Consent to Participate

This case control study was approved by the research ethics committee of the Faculty of Medicine of Monastir (IORG 0009738 N° 54 OMB 0990-0279. Informed consent was obtained from each research subject.

Informed Consent

Informed consent was obtained from all subjects involved in the study.

Data Availability

The data that support the findings of this study are available on request from the corresponding author: saadellaouiines5@gmail.com

Acknowledgment

We thank all the staff from the Child psychiatry department and Stomatology department in Hedi Chaker University Hospital in Sfax. Special thanks to professor Khalil Chtourou who contributed to Data analysis.

Conflict of Interest

The authors declare no conflict of interest.

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