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FACT SHEET: Bipolar Disorder  is also known as “bipolar affective disorder”, “manic-depressive illness”, and “bipolar illness”. Bipolar and related disorders1 include: “bipolar disorder I” (BD-I); “bipolar disorder II” (BD-II); “cyclothymic disorder” (also known as “cyclothymia”); “specified bipolar and related disorders”; and “unspecified bipolar and related disorders”.

Date of Publication: June 20, 2019
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Note: Unless otherwise specified, this fact sheet primarily addresses the manic and hypomanic aspects of bipolar and related disorders. Depression is addressed in more detail in a separate fact sheet.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No, unless the patient/client displays manic, catatonic, or psychotic behaviour that poses a risk to himself/herself or the dental hygienist during procedures (e.g., pronounced distractibility, psychomotor agitation, or disorganized behaviour).

Is medical consult advised?

  • No, if bipolar disorder has been previously diagnosed and is well controlled.
  • Yes, if bipolar disorder is newly suspected (e.g., manic behaviour) or poor control of previously diagnosed bipolar disorder is suspected (e.g., manic or depressive signs/symptoms). Immediate referral is indicated if suicidality is suspected.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • No, unless the patient/client displays manic, catatonic, or psychotic signs/symptoms that pose a risk to self or the dental hygienist during procedures (e.g., pronounced distractibility, psychomotor agitation, or disorganized behaviour).

Is medical consult advised?

  • See above.

Is medical clearance required? 

  • No, unless severe leukopenia (i.e., reduced white blood cell count, and hence immunosuppression) or thrombocytopenia (i.e., reduced platelet count, and hence increased bleeding risk) is suspected with mood-stabilizing medication (particularly carbamazepine and valproic acid) or antipsychotic medication (particularly quetiapine, clozapine, and the phenothiazine2 class) use. [This would be a rare situation in the dental hygiene office setting.] 

Is antibiotic prophylaxis required?

  • No (in the absence of immunosuppression, for which prophylaxis may be a consideration).

Is postponing treatment advised?

  • No, unless:
    • medical clearance is pending regarding possible immunosuppression or thrombocytopenia associated with mood-stabilizer or antipsychotic use;
    • the patient/client exhibits manic, catatonic, or psychotic signs/symptoms that may pose risk during, or cause inability to perform, procedures, in which case medical treatment is first needed; or 
    • severe signs/symptoms of depression exist (in which case attainment of better depression control may be indicated before attempting elective dental hygiene procedures).

Oral management implications

  • The dental hygienist should be alert for mood swings. In a severe manic or depressive episode of bipolar disorder, catatonic signs/symptoms (e.g., extreme physical agitation or refusal/inability to open mouth or speak) augur against performance of dental hygiene procedures.
  • The dental hygienist should determine if the patient/client has the capacity to give informed consent.
  • Stimuli (e.g., noise and light) should be reduced to the extent possible to avoid overstimulation, a susceptibility in bipolar disorder.
  • In patients/clients with mania or hypomania, conversations should be kept brief and focused only on immediate matters. 
  • The dental hygienist should be alert for signs/symptoms of leukopenia (e.g., recurrent and persistent oral infections/lesions and sore throat) and/or thrombocytopenia (e.g., petechiae) in patients/clients taking carbamazepine, valproic acid, or certain antipsychotic drugs.
  • The dental hygienist should be alert for signs/symptoms of alcohol and illicit drug misuse, including missing teeth. Referral for addiction counselling or to a physician may be indicated.
  • The dental hygienist should be alert for signs/symptoms of poor nutrition. Referral to a dietitian or physician may be indicated.
  • For medication-induced Parkinsonian muscle side effects, a bite block and low volume suction during dental hygiene procedures may be helpful.
  • Management of iatrogenic xerostomia is important.
  • To reduce patient/client-induced gingival trauma and tooth abrasion, use of a soft toothbrush should be encouraged. Grinding of teeth can be managed with a bruxism appliance.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), erythromycin, tetracycline, and metronidazole increase serum lithium levels, potentially leading to toxicity. Thus, they should be used cautiously, if at all, in patients/clients taking lithium.
  • Because antipsychotic drugs may potentiate the sedative action of tranquilizer and opioid medications, if the latter are used, their dosage may need to be reduced to avoid serious respiratory suppression.

Oral manifestations

  • Dental abrasion can result from overzealous brushing and flossing during the manic/hypomanic phase of bipolar disorder, as can gingival and mucosal lacerations.
  • Neglect of oral hygiene, and its sequelae, can occur during depressive episodes.
  • Bruxism and caries occur at elevated rates.
  • Xerostomia is a side effect of some antidepressants (e.g., tricyclics), mood stabilizers (including lithium and lamotrigine), and some antipsychotics (e.g., quetiapine). Heavy tobacco and caffeine use further exacerbate dry mouth and related oral manifestations.
  • Lichenoid stomatitis, dysgeusia (often “metallic” in nature), and burning mouth syndrome can result from lithium use.
  • Damage to tooth enamel and mouth ulcers are side effects of lamotrigine.
  • Mastication muscle spasms, pseudoparkinsonianism (resulting in a mask-like face and drooling), lip smacking, and tongue protrusion can result from antipsychotic use (in the atypical class, most notably risperidone).
  • Erosion of tooth structure, rapid decay, periodontal disease, and other suspicious lesions may result from illicit drug abuse.
  • Gingivitis, breakdown of mucosal tissue, and periodontal destruction may result from inadequate nutrition associated with either manic or depressive episodes.

Related signs and symptoms

  • Bipolar disorder is characterized by unusual shifts in mood, energy, activity levels, and the ability to carry on everyday tasks. Its cause is linked to various factors, including genetic predisposition and alterations in brain chemistry3 and structure4. Like most mood disorders, bipolar disorder tends to be cyclic.
  • Bipolar disorder affects about 1% to 2% of the adult Canadian population. Most persons are in their teens or early 20s when the symptoms of bipolar disorder first appear; onset is rare over 50 years of age. 
  • Bipolar disorder occurs with equal frequency in both sexes. However, men tend to have a greater number of manic and depressive episodes than women. On average, 10 episodes are experienced in a lifetime, and untreated episodes may last months. 
  • Patients/clients with bipolar and related disorders have at least one episode of mania, hypomania (“mild mania”), or hypomanic symptoms. Most persons who become manic or hypomanic will eventually experience depression, and many patients/clients initially experience depression followed by mania or hypomania.
  • Types of bipolar and related disorders include:
    • bipolar I disorder, which entails at least one manic episode that lasts at least 7 consecutive days (or which is so severe that the person requires hospitalization), usually, but not necessarily, interspersed with depressive episodes lasting at least 2 weeks (i.e., major depression), or a mixture of manic and depressive signs/symptoms that occur at the same time, and which is not attributable to the physiological effects of a substance or general medical condition. 
    • bipolar II disorder, which entails at least one hypomanic episode (but not full-blown mania as in BD-I) that lasts at least 4 consecutive days and a major depressive episode, and which is not attributable to the physiological effects of a substance or general medical condition. 
    • cyclothymic disorder, which manifests as recurrent brief episodes of hypomanic signs/symptoms and numerous periods of mild depressive signs/symptoms ongoing for at least 2 years in adults (1 year in children and adolescents).
    • specified bipolar and related disorders, which entail bipolar-like phenomena that do not meet the criteria for BD-I, BD-II, or cyclothymic disorder due to insufficient duration or severity.
    • unspecified bipolar and related disorders, which entail symptoms of bipolar and related disorders that cause significant distress or impairment but do not meet the full criteria for any other category.
  • Between episodes of mania/hypomania or depression, many patients/clients are free of mood changes, but some persons have lingering symptoms. 
  • A manic or hypomanic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behaviour5 or energy. Associated phenomena include: inflated self-esteem or grandiosity; decreased need for sleep; excessive talking; flight of ideas or racing thoughts; high distractibility; psychomotor agitation (non-goal-directed activity); and excessive involvement in activities that have a high potential for painful consequences (such as engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)6. Increased appetite may also occur. A hypomanic episode is much less severe than a manic episode, and it does not result in impaired social or occupational functioning or require hospitalization.
  • In mania, speech is often rapid, loud, and difficult to interpret. Behaviour may be demanding and intrusive. Style of dress may be strange and colourful.
  • Psychosis7 can occur in a patient/client with severe episodes of mania or depression.
  • Catatonic signs/symptoms (i.e., movement problems) occur in up to about 25% of patients/clients with pure or mixed manic episodes or with depression. These motor problems vary and may include extreme physical agitation, slowness, or odd postures or movements. 
  • Some patients/clients with bipolar disorder exhibit episodes of mania or hypomania linked to a specific season. For example, spring and summer can trigger symptoms of mania or hypomania. Patients/clients may also experience depressive episodes during the fall and winter months akin to seasonal affective disorder of major depression.
  • Patients/clients who have bipolar disorder are at elevated risk of migraine headaches, obesity, diabetes mellitus, and other physical illnesses. Anxiety, attention-deficit hyperactivity disorder (ADHD), binge eating disorder, alcohol and drug misuse, personality disorder, and obsessive compulsive disorder are common co-morbidities. Long-term lithium use is associated with hypothyroidism, nontoxic goitre8, cardiac arrhythmias, and diabetes insipidus9. 
  • Some patients/clients with bipolar disorder experience only one manic or hypomanic episode, although the condition is usually considered a lifelong illness. Many affected persons take a mood stabilizer (usually lithium) on an ongoing basis and experience less frequent or severe episodes and function well, whereas others continue to have frequent and/or severe episodes with ongoing disability despite treatment.
  • Bipolar disorder can lead to death. Suicide risk is significant.

References and sources of more detailed information


Date: November 30, 2017
Revised: February 6, 2022; June 16, 2025


FOOTNOTES

1 This classification of bipolar and related disorders is based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), published by the American Psychiatric Association.
2 Phenothiazines (e.g., chlorpromazine, thioridazine, fluphenazine, prochlorperazine, perphenazine, and trifluoperazine), which are an older category of antipsychotic medications, may be used in the management of bipolar disorder when the patient/client fails to respond to, or can no longer take, lithium. However, their use has largely been supplanted in recent years by generally safer, better tolerated, and more efficacious “atypical” antipsychotics, including quetiapine, risperidone, olanzapine, clozapine, and aripiprazole.
3 Reduced brain concentrations of the neurotransmitters serotonin and norepinephrine have been linked to depression, and increased levels are thought to contribute to mania, although the definitive cause(s) of bipolar disorder is unknown.
4 Treatment of bipolar disorder includes pharmacotherapy, psychotherapy (such as cognitive behavioural therapy), electroconvulsive therapy (ECT), and repetitive transcranial magnetic stimulation (rTMS). Drug treatment of bipolar disorder has two goals: firstly, rapid control of symptoms in acute episodes of mania and depression, and, secondly, prevention of future episodes and reduction in frequency and severity. The mainstays of drug therapy are mood-stabilizing drugs (some of which are also anticonvulsants), which include lithium carbonate (most commonly used), valproic acid, divalproex sodium, carbamazepine, and lamotrigine. As well, atypical antipsychotics (such as quetiapine and olanzapine) are sometimes used in conjunction with mood-stabilizers or as antidepressants in bipolar disorder. Mixed manic and depressive episodes are challenging to manage; often, the manic behaviour needs to be first stabilized with a mood-stabilizer or atypical antipsychotic, and then depression is addressed with an antidepressant drug (e.g., fluoxetine).
5 The abnormal and persistent goal-directed behaviour may manifest socially, at school or work, or sexually.
6 This poor judgement may result in legal and financial problems.
7 Psychotic symptoms include hallucinations (hearing, seeing, tasting, smelling, or feeling something that is not really present) and delusions (false beliefs with no basis in reality). By definition, a patient/client with a bipolar disorder who exhibits psychosis (without another underlying cause) is classified as BPD-I (i.e., has mania), not BPD-II (i.e., does not have hypomania).
8 Goitre is generalized enlargement of the thyroid gland.
9 Diabetes insipidus is characterized by polyuria (large amounts of urine) and polydipsia (increased thirst), which, in the case of long-term lithium use, is thought to be caused by drug effects on the kidneys.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.