The Behavior of Patients with Obsessive-Compulsive Disorder in Dental Clinics

Objectives This review documents published obsessive-compulsive disorder (OCD) cases with dental and oral conditions with potential impact on the dental procedure. The research question was, what are the psychiatric and behavioral features of people with OCD that might affect dental sessions? Methods This review followed the PRISMA guidelines (PROSPERO registration No. CRD42020212371). Six databases (PubMed, Scopus, Web of Science, LILACS, Cochrane Library, and PsycINFO) were screened for published clinical studies that report dental patients with obsessions or compulsions behaviors as identified by National Institute of Mental Health (NIMH). Inclusion of the studies was performed according to the eligibility criteria. The quality evaluation was carried out using the Joanna Briggs Institute's (JBI) Critical Appraisal Checklist. The results were qualitatively assessed for synthesis. Results After elimination of duplication, 530 articles were screened, and 35 articles were evaluated for eligibility. 17 studies met the inclusion criteria (8 case reports, 5 cross-sectional studies, 1 longitudinal cohort study, and 3 case-control studies) and were included in the review. All case reports demonstrated symptoms of obsessions or compulsions such as fear of germs and contamination, aggressive thoughts, having things symmetric in perfect order, excessive cleaning or handwashing, repeatedly checking things, and compulsive counting. OCD-related behavior was assessed in the included clinical investigations using standardized protocols such as Florida Obsessive-Compulsive Inventory, Symptom Checklist-90-Revised, 4-item Corah Dental Anxiety Scale, Diagnostic and Statistical Manual of Mental Disorders, and the Crown Crisp Experimental Index. Quality assessment of the 17 included articles revealed 14 articles with low risk of bias and 3 articles with moderate risk of bias. Conclusion The reported OCD symptoms may implement psychological difficulties during dental procedures without affecting the outcome. Although there was no contraindication for planning or performing dental treatments for a patient with OCD, dental-related procedures and protocols might be modified for successful dental appointments.


Introduction
Obsessive-compulsive disorder (OCD) is a severe psychological disorder, with global prevalence of 2-3% [1]. e major characteristics of OCD include obsessional debilitating inner thoughts associated with repetitive behaviors [1]. OCD can be presented in four types of obsessive symptoms as identified by the National Institute of Mental Health (NIMH) including (1) fear of infection, germs diseases, and contamination; (2) aggressive thoughts against self or others; (3) impious thoughts; and (4) worries about symmetry and perfectionism [2].
According to these intrusive thoughts, obsessive patients feel the urge toward some behaviors as frequent washing and cleaning, checking things repetitively, and compulsive counting. OCD always shows two modes of onset. By approaching 11 years of age, the first peak starts and then in the early adulthood the second peak begins. Almost by 10 years of age, symptoms appear in around 20% of the affected population [3].
Several psychological symptoms might hinder the success of dental procedures and can give the dentist hard time during treatment periods. Due to fear of infection, patients with OCD may be distrusted about the disinfection and cleanliness of the materials, tools, table, and dental chair, which may irritate the dentist. erefore, taking a complete medical history, including psychiatric, along with consulting the patient's psychiatric physician is a vital step to avoid dental problems or oral conditions. Moreover, dentists should be aware of OCD diagnostic criteria as they might be the first ones to suspect that their patients may be diagnosed with OCD by correlating patient's behavior with OCD diagnostic criteria. In this context, this review aims to familiarize dentists with OCD behavioral characteristics that were reported in dental clinics, which could be helpful to complete dental treatment sessions of patients with OCD successfully.

Protocol and Registration.
e protocol of this review was performed in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [4]. Registration of the protocol was done in International Prospective Register of Systematic Reviews (PROSPERO) platform with the Centre for Reviews and Dissemination at the University of York under code CRD42020212371.

Review Question.
e focus question in this review was, "what are behavioral characteristics of individuals with OCD in dental clinics?"

Search Strategy.
A structure online database search was conducted independently by the two reviewers the till the 24th of December 2020. Searches were performed on six different electronic databases: PubMed, Scopus, Web of science (WoS), Latin American & Caribbean Health Sciences Literature (LILACS), Cochrane Library, and PsycINFO. e organization and duplicated articles exclusion were carried out by EndNote online ( omson Reuters, Philadelphia, USA). For each database, numerous words' combinations were done including "Obsessive compulsive disorder" AND "Dental" OR "Dentistry" OR "Periodontal" OR "Periodontitis" OR "Gingiva" OR "Orthodontic" OR "Dental implant" OR "Maxillofacial" OR "Teeth" OR "Tooth" OR "Tooth Extraction" OR "Pediatric dentistry" OR "Dental prosthesis" OR "Denture" OR "Bleaching" OR "Caries" OR "Amalgam" OR "Composite" OR "Oral lesion" OR "Tongue" OR "Edentulous" OR "Endodontic" OR "Pulp." 2.4. Eligibility Criteria. Articles of this review were chosen based on the PICOS elements (Table 1), where population (P) � dental patients diagnosed with OCD, intervention (I) � different dental procedures, comparison (C) � dental patients free from OCD, outcome (O) � clinical difficulties during dental treatment sessions, and study design (S) � published case reports, case series, cohort, cross-sectional, case-control, or randomized clinical studies. Only articles that were published in English language were considered.

Study Selection.
e study screening and selection process was carried out in two separate stages. At the first stage, the retrieved articles after the preliminary search of databases were evaluated according to their titles and abstracts by the two reviewers independently. e initial stage was followed by a second stage at which each identified study was reviewed in accordance with the inclusion/exclusion criteria by both reviewers, where each author constructed an independent list of selected articles. e lists were matched, revised, and compared. Duplicated studies were excluded. Contrarieties were finalized by discussion. e final list of the selected articles was checked independently for comprehensiveness and validity.

Data Extraction.
e extracted and incorporated articles were piloted on standardized tables for data collection. Articles were screened and data from each article was extracted and tabulated in relation to demographic data such as author names and publication year and country. In addition, study design, sample size, characteristics of the participants, reported OCD behavior (as identified by NIMH), method of behavior assessment, acceptance of dental treatment, dental chief complaint, dental interventions, and major study findings were also collected in standard tables independently by the two reviewers.

Risk of Bias (Quality) Assessment.
e quality of each included article was assessed independently by each author using the Joanna Briggs Institute's (JBI) Critical Appraisal Checklist for each type of the included studies [5]. Each article was assessed by multiple questions and the reviewer selected one answer for each question from "yes," "unclear," "no," or "not applicable." Articles were evaluated based on the following criteria: (LOW risk of bias) studies with more than 70% "yes" score; (MODERATE risk of bias) studies with 50% to 69% "yes" score; and (HIGH risk of bias) studies with less than 49% "yes" score. As recommended by the JBI reviewers' manual, all decisions regarding the scoring system and cut-off points were approved by all reviewers before the start of the critical appraisal process.

Syntheses of Results.
e collected data from the included studies was qualitatively assessed for results synthesis. ere was not enough homogeneity between collected articles, particularly in study design, and their outcomes. Henceforth, outcomes of these studies were explained in a narrative approach.

PICOS
Inclusion criteria Exclusion criteria Population Patients having dental or oral condition and diagnosed with OCD. Patients with or without psychological disorder other than OCD.

Intervention
All dental procedures including preventative, conservative, or maxillofacial surgeries. Medical interventions without dental contribution.

Comparison
Mental and psychologically normal dental patients.
Dental patients with psychiatric disorder other than OCD.

Outcome
Practicing difficulties associated with patients with OCD in dental clinics.
Clinical practicing complications related to people with OCD in nondental clinics.

Study design
Published case reports, case series, cohort, crosssectional, case-control, or randomized clinical studies.
Conference abstract, editorial correspondence, book chapters, studies not involving human subjects, or review articles assessed case-control studies, two exhibited low risk of bias, while one article [22] showed moderate risk of bias. e overall scores for case-control studies were as follows: 80% for Kim et al.'s study [20], 70% for Velly et al.'s study [21], and 60% for the study of Zach and Andreasen [22].

Syntheses of Results.
e outcomes of all included clinical investigations were collected and tabulated (Table 5). For instance, clinical studies varied in their design including 5 cross-sectional studies, 1 longitudinal cohort study, and 3 case-control studies. Case reports were mainly a qualitative Frequency of obsessive-compulsive symptoms and related factors in medical and dental students of kurdistan university of medical sciences, 2018 Assessment of OCD was carried out in medical and dental students. Dental patients were not involved in this study. 2 Budman and Sarcevic [24] An unusual case of motor and vocal tics with obsessive-compulsive symptoms in a young adult with Behçet's disease A case report that describes nondental patient with Behcet's disease who showed motor and vocal tics with OCD. 3 Cassin et al. [25] Quality of life in treatment-seeking patients with obsessive-compulsive disorder with and without major depressive disorder A study that compares the quality of life of a patient with OCD in relation to depression comorbidity. Dental patients were not involved in this study. 4 Cockburn et al. [31] Oral health impacts of medications used to treat mental illness e study design is a review article. 5 de Jongh [39] Mental problems in the dental practice: a compulsive disorder e article was written in Dutch.

6
De Stefano et al. [32] Fear and anxiety managing methods during dental treatments: a systematic review of recent data e study design is a review article. 7 Dougall and Fiske [33] Access to special care dentistry, part 6. Special care dentistry services for young people e study design is a review article. 8 Doukhan et al. [26] A case of bleach addiction associated with severe obsessive-compulsive disorder A case report that describes a patient having OCD with bleach use addiction (not related to dental use or teeth bleaching). 9 Elmgreen and Danielsen [40] OCD and orofacial dyskinesia caused by a rare basal ganglia disorder e article was written in Danish. 10 Friedlander and Eth [34] Dental management considerations in children with obsessive-compulsive disorder e study design is a review article. 11 Friedlander and Serafetinides [35] Dental management of the patient with obsessivecompulsive disorder e study design is a review article. 12 Friedlander and Cummings [36] Dental treatment of patients with Gilles de la Tourette's syndrome e study design is a review article. 13 Hollander et al. [28] A placebo controlled crossover trial of liquid fluoxetine on repetitive behaviors in childhood and adolescent autism e article describes the effects of fluoxetine as a selective serotonin reuptake inhibitor liquid on the repetitive behaviors in 45 child or adolescent patients with autism spectrum disorders (ASDs). OCD behaviors were not reported in this study.
14 Kayhan et al. [27] Obsessive-compulsive disorder concurrent with Melkersson-Rosenthal Syndrome: A case report A case report that describes a patient with OCD and Melkersson-Rosenthal Syndrome (MRS). e patient was admitted to psychiatry department without reporting dental-related symptoms. 15 Keim [37] e most difficult cases e article is an editor's corner. 16 Moore and Hersh [38] Common medications prescribed for adolescent dental patients e study design is a review article. 17 Paterson and Watson [29] Case report: prolonged match chewing: an unusual case of tooth wear A report that describes a case of sand eating habit that caused abrasive tooth wear. e patient was not diagnosed with OCD. 18 Rahman et al. [30] Oral health status of patients with psychiatric problem A cross-sectional study that examined the oral health status of 75 psychiatric patients. e major reported mental illness was schizophrenia. OCD was not reported in these patients. 4 International Journal of Dentistry description of the reported cases. In addition, qualitative assessment of the included clinical studies revealed separate outcomes. One study suggested that the behavior of patients diagnosed with OCD could be improved following orthognathic surgeries [14]. Another study showed that trauma history in patients with TMD may have psychological impact [20]. Studies also found a direct proportional correlation between dental anxiety and psychological disorders such as OCD [18,19]. Psychological disorders in general were considered to be linked with different dental-related problems including atypical odontalgia [15], dentofacial correctness seeking [16], pain [17,21], and temporomandibular joint (TMJ) problems [22]. erefore, findings of these studies were discussed in comprehensive manner.

Discussion
Several studies have documented the impact of psychologic disorders and patient's mental health status on the oral health and dental practice. In the present review, we reported data from published literature on OCD-related psychological behaviors and their impact on dental treatment procedures and session planning. Obsessions or compulsions symptoms were documented in case reports of dental patients with OCD such as fear of germs and contamination, aggressive thoughts toward others or self, having things symmetric in perfect order, excessive cleaning or handwashing, ordering, arranging things in a particular way, repeatedly checking things, and compulsive counting were reported. Large clinical studies also reported OCD-related behaviors in dental patients that were assessed by multiple behavioral assessment methods including FOCI [41], SCL-90-R [42], DIS [43], DSM-5 [44], and CCEI [45].
Assessing the behavior of OCD dental patients was conducted in this review. In the eight selected case reports, dental patients with OCD showed different OCD-related obsessions or compulsives that resulted in difficulties or modifications of their dental procedures. Ahuja et al. [6] and Chandna et al. [8] stated that their patients could get agitated easily, if they were not relieved frequently through the treatment sessions that everything around them such as dental tools and dental chair is cleaned and disinfected. Sometimes things were cleaned in front of them to reassure them. ey also used to count in a specific pattern during the treatment. Castellanos-Cosano et al. [7] showed that there was no contraindication in placing a dental implant in a patient with OCD after consulting the patient's psychologist.
ey also pointed that their patient may refuse the dental International Journal of Dentistry 5 treatment but, with the guardian consent, treatment can be conducted safely. Fontenelle and Leite [9] demonstrated that their patient developed oral self-mutilations resistant to medications. However, these symptoms subsided after fabricating an ordinary mouth guard. e included case reports also argued that OCD-related thoughts can lead to serious dental conditions. Herren and Lindroth [10] revealed that their patient was locked up in the idea of tapping on her teeth in a specific manner before carrying out her daily activities, which results in multiple teeth wear. e dentist in this case preferred to postpone her dental treatment to allow drugs for OCD and behavioral therapy to take place first. Moreover, Michael [11] declared that his case was caged in the idea of teeth brushing that took a very long time (up to four hours every night), which affected her day schedule. After adopting exposure and response protocol in treatment of OCD, the patient eventually started to take over her inner thoughts of prolonged teeth brushing. Vieira et al. [12] showed that the patient consumed unhealthy diet for years due to inner fears of insecticides in vegetables. He also had similar fears toward chemicals in toothpastes, which was reflected on his tooth brushing habits. All these behaviors ended with scurvy presented with severe gingival bleeding and palatal lesions. After modulating his diet and introducing vitamin C supplement, symptoms started to vanish. Oulis et al. [13] presented an interesting case of a woman with a 40-year history of severe OCD managed by fluoxetine or escitalopram. She developed bruxism because of these medications. However, symptoms of bruxism subsided after adding aripiprazole to her regimen. e selected clinical studies also reported correlation between OCD behaviors and dental complains or symptoms. Haberle et al.'s [14] study identified OCD as one of the common comorbid symptoms noticed among patients undergoing orthognathic surgeries. e OCD symptoms were markedly diminished postoperatively as indicated by reduced index of FOCI. is made the authors suggest that jaw deformities may induce more psychological concerns or even obsessions regarding the facial appearance. Out of the 383 patients with atypical odontalgia in Miura et al.'s work [15], 177 showed comorbid psychiatric disorders including OCD, which was observed in 4 patients (1%). Overall, this study suggested that psychological disorders such as OCD in patients with atypical odontalgia might trigger pain emotional response. In Phillips et al.'s study [16], 194 patients, who were going to have orthognathic surgeries, completed  17 Zach and Andreasen [22] Evaluation of the psychological profiles of patients with signs and symptoms of temporomandibular disorders USA 1991 Case-control study 6 International Journal of Dentistry Bruxism induced by OCD medications was treated by aripiprazole. * Obsessions: a: fear of germs and contamination; b: unwanted forbidden or taboo thoughts involving sex, religion, or harm; c: aggressive thoughts toward others or self; d: having things symmetric in perfect order. * * Compulsions: a: excessive cleaning or handwashing; b: ordering and arranging things in a particular way; c: repeatedly checking things; d: compulsive counting.  [17], 1202 patients with psychiatric illness were evaluated based on the DSM-5. 0.3% of the patients (4 patients) were diagnosed with OCD. One patient with OCD showed oral manifestation such as oral dysesthesia. is study suggested that, beside physiological causes, psychiatric disorders augment orofacial pain. In Liu et al.'s study [18], the preoperative anxiety along with postoperative satisfaction was assessed in 92 patients undergoing anterior dental implant surgeries. In this study, evaluation of OCD symptoms by SCL-90-R revealed that SCL-90-R scores were not significant between study subjects and norm of Chinese. Locker et al. [19] assessed dental anxiety and psychological disorders, such as major depressive episode, dysthymia, generalized anxiety disorder, panic disorder, agoraphobia, social phobia, simple phobia, obsessive-compulsive disorder, conduct disorder, cannabis, and alcohol dependence among 805 subjects using the Dental Anxiety Scale (DAS) [46] and the DIS, respectively. e prevalence of OCD was 4.1% with no significant difference between males and females. In this study, 4% of the nonanxious dental patients had OCD, while OCD was reported in 3.2% and 8.3% of the moderately and severely anxious dental patients, respectively. After correlating, it was found that, within the selected population, the assessed psychological disorders play a significant role in the maintenance of dental anxiety. In Kim et al.'s study [20], the SCL-90-R was employed for the assessment of the psychological characteristics, including OCD, in patients with TMD. Collectively, this study concluded that trauma history may induce additional significant subjective, objective, and psychological impairments among patients diagnosed with TMD. Velly et al. [21] correlated masticatory myofascial pain (MFP) and psychological factors (assessed by SCL-90-R) in 83 chronic MFP cases and 100 controls. 55 MFP and 74 controls showed symptoms of OCD behaviors. Consequently, the authors proposed that MFP and psychological symptoms might be bidirectionality correlated. Zach and Andreasen [22] evaluated the psychological features of 98 females with TMD symptoms using the CCEI against 98 other control females. e mean OCD profile scores between patients with TMD and control were 5.32 (±3.15) and 4.89 (±2.82), respectively, whereas the difference between the two means was not statistically significant (p � 0.3358). Although this study did not report direct correlation between OCD symptoms and TMD, it showed that OCD may have impact on dental health after excluding nonorganic reasons.
To the best of our knowledge, this is the first review that comprehensively reports the published behavioral symptoms of patients with OCD in dental clinics to evaluate the impact of these psychological symptoms on dental procedures and sessions planning. Another strength point in this review is that articles selection procedure was adherent to the PRISMA guidelines along with prior registration of the protocol with the PROSPERO database, which indicates greater quality of the reporting with minimal bias risks. We were not able to conduct meta-analysis in the present review due to the heterogeneity among the included studies. e included reports qualitatively described the cases with no reported quantitative assessment. In the clinical studies, assessment of the OCD behavioral related symptoms was carried out using multiple procedures. In addition, several dental specialties were involved, which were associated with variable dental sign and complaints. Outcomes and conclusion of these clinical studies were correlated with psychiatric and psychological disorders in general, which could not be applied on patients diagnosed with OCD specifically due to their low number.

Conclusion
According to the selected articles, symptoms of OCD could be reported in dental clinics. OCD-related obsessions or compulsive behaviors might produce some difficulties during dental procedures but do not markedly affect the dental treatment. Moreover, OCD is not contraindicated in dental treatments including surgeries such as orthognathic surgeries or placement of dental implants. Like other psychological disorders, OCD might add an extra dental anxiety burden and influence the patient's satisfaction. Dentists should consider flexibility during treating patients with OCD.

Data Availability
e data used to support the findings of this study are included within the article. Table 6: Response to JBI's Critical Appraisal Checklist for each type of the included studies (assessment of risk of bias).