FACT SHEET: Obsessive Compulsive Disorder (also known as “OCD”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
Is medical consult advised?
- No, if OCD has been previously diagnosed and is well controlled.
- Yes, if OCD is newly suspected or poor control of previously diagnosed OCD is suspected.
- Yes, if severe xerostomia is suspected to be related to antidepressant use (which may improve if an alternative medication is a consideration).
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- No, unless the patient/client displays signs/symptoms of obsessive compulsive disorder that pose a risk to himself/herself or the dental hygienist during procedures (e.g., inability to sit still, etc.).
Is medical consult advised?
- See above.
Is medical clearance required?
- No, unless:
- severe leukopenia (i.e., reduced white blood cell count, and hence immunosuppression) is suspected with tricyclic antidepressant (TCA) use. [This would be a very rare situation in the dental hygiene office setting.]
Is antibiotic prophylaxis required?
- No (in the absence of immunosuppression).
Is postponing treatment advised?
- No, unless:
- medical clearance is pending regarding possible immunosuppression associated with TCA use;
- the patient exhibits signs/symptoms of OCD (e.g., significant agitation) that may pose risk during, or cause inability to perform, procedures, in which case medical intervention may first be needed; or
- severe signs/symptoms of OCD exist, for which better OCD control may be indicated to alleviate patient/client’s distress before attempting elective dental hygiene treatment.
Oral management implications
- Due to their ongoing relationship with patients/clients, dental hygienists are in a position to detect some manifestations of OCD and to initiate medical consultation as appropriate.
- Patient/client obsessions (i.e., OCD thoughts) and compulsions (i.e., OCD behaviours or mental acts) that may interfere with, or require modification of, delivery of dental hygiene care include:
- persistent lateness for appointment (because OCD rituals are time-consuming, including checking locks and counting steps);
- unrealistic fear of dental chair or equipment contamination with germs;
- need to have dental chair in a certain position;
- insistence on doing things in a particular way;
- anxiousness or agitation if patient/client’s wishes are not followed exactly;
- washing hands excessively; and
- repeating, counting, or checking excessively.
- In order to mitigate harm, regular dental/dental hygiene appointments are important for patients/clients with compulsions (e.g., excessive brushing and/or flossing of teeth) that can compromise oral health.
- Measures that the dental hygienist can take to alleviate patient/client anxiety about germs include:
- ensuring the patient/client can see you washing your hands and putting on a new mask and gloves;
- showing the patient/client the unopened sterilized package or cassette of instruments;
- informing the patient/client that prophy cups, saliva ejectors, etc., are either disposable or sterilized for their protection.
- making sure the operatory looks and smells clean;
- ensuring the underside of the “over the chest” delivery system is clean with no dust, residue, or biological burden; and
- reclining in your own patient/client chair to see what the patient/client sees. (For example, is the ceiling in good repair?)
- Excessive, ritualized brushing of teeth is a common compulsion in patients/clients with OCD. Signs/symptoms resulting from this obsessive focus on oral cleanliness include gingival recession (which may lead to tooth sensitivity); gingival irritation (e.g., ulcerations, bleeding, and pain); abrasions of the teeth; and worn-down tooth enamel (and therefore susceptibility to cavities).
- Gingival lesions may result from self-inflicted injuries caused by floss, toothpicks, fingernails, and other materials.
- Abrasions to the oral mucosa can result from continual spitting intended to get rid of perceived contamination.
- Neglect of oral hygiene occurs in some patients/clients with OCD due to their pre-occupation with washing their hands or other obsessions, which crowds out other self-care activities.
- Temporomandibular joint (TMJ) disorder can result from chronic nail biting.
- Xerostomia is a side-effect of antidepressants used to treat OCD, including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants1.
- Dysgeusia (altered sense of taste) can be a side effect of tricyclics.
- Bruxism is associated with SSRI use.
- Stomatitis may result from TCA use.
- Sialadenitis, tongue edema, and tongue discolouration may result from TCA use.
Related signs and symptoms
- OCD is a disorder in which affected people have recurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do something repetitively (compulsions). The repetitive behaviors or mental acts — such as hand washing, checking on things, or cleaning — can significantly interfere with a person’s daily activities and social interactions. For people with OCD, thoughts are persistent, and behaviors and mental acts tend to be rigid and structured (although may change, particularly in very complex behaviours), and not performing the behaviors or mental acts typically causes significant distress.2
- Many affected people know or suspect their obsessions are not realistic, but others may think they could be true (i.e., limited insight). Even if they know their obsessions are not realistic, persons with OCD have difficulty freeing themselves from the obsessive thoughts or stopping the compulsive actions.
- 1% to 3% of people have OCD, and, among adults, slightly more women than men are affected. Onset often occurs in childhood, adolescence, and early adulthood, with average age of symptoms appearance being 19 years old.
- OCD is generally considered a life-long disorder. Patients/clients can have mild to moderated signs/symptoms, or the condition can be so severe and time-consuming as to be disabling.
- Formerly classified as an anxiety disorder, OCD is now recognized as a distinct clinical entity, albeit one where anxiety is the most common manifestation.3
- Common obsessions include:
- fear of being contaminated by people or the environment;
- fear of harm to oneself or a loved one;
- fear of blurting out obscenities or insults;
- extreme concern with order, symmetry, or precision;
- driving need to do things perfectly or correctly;
- disturbing sexual thoughts or images;
- recurrent intrusive thoughts of sounds, images, words, or numbers; and
- fear of losing or discarding something important.
- Common compulsions include:
- excessive or ritualized hand washing, showering, or toileting;
- repeated cleaning of household objects;
- ordering or arranging things in a certain way;
- repeatedly checking locks, switches, or appliances;
- continually seeking approval or reassurance; and
- repeated counting to a certain number.
- Signs/symptoms of OCD tend to come and go over time, and they generally worsen when one is under stress.4
References and sources of more detailed information
- College of Dental Hygienists of Ontario
- Chandna P, Srivastava N, Adlakha V. Obsessive compulsive disorder in dental setting. Journal of the Indian Society of Pedodontics and Preventive Dentistry. 2014;32(4):330-332. 10.4103/0970-4388.140964. https://www.jisppd.com/article.asp?issn=0970-4388;year=2014;volume=32;issue=4;spage=330;epage=332;aulast=Chandna
- Arora L, Shahi N, Sharma A, Philip S, Pal Singh A. Dental Manifestations of Obsessive Compulsive Disorder: A Case Series. Delhi Psychiatry Journal. 2013;16(1):115-119.
https://www.healthlinkbc.ca/health-topics/hw169097 (What is Obsessive Compulsive Disorder)
- American Psychiatric Association
- RDH Magazine
- Mayo Clinic
- International OCD Foundation
1 Fluoxetine, fluvoxamine, paroxetine, and sertraline are SSRIs commonly used to treat OCD, whereas clomipramine is a TCA that is sometimes used. The SSRI dosage used to treat OCD is typically higher than that used to treat depression.
2 A formal diagnosis of OCD requires the presence of obsessions and/or compulsions that are time consuming (i.e., more than one hour a day), cause significant distress, and impair work or social functioning.
3 OCD is distinguished from disorders such as tic disorders, trichotillomania, and anorexia nervosa, because in these disorders obsessions are limited to a specific obsession only (e.g., hair pulling in trichotillomania). In OCD, obsessions and compulsions typically range over multiple thoughts and behaviours. Similarly, OCD is distinct from generalized anxiety disorder, for the obsessions in OCD are considerably more intrusive and socially unacceptable.
4 Treatment of OCD commonly improves an individual’s quality of life and ability to function in society. Therapeutic options include: cognitive behavioural therapy; antidepressant medications; care giver interventions (e.g., exposure practice at home); self-care (i.e., healthy lifestyle and relaxation techniques such as yoga, meditation, visualization, and massage); neurosurgical treatment (e.g., deep brain stimulation [DBS]); and transcranial magnetic stimulation (TMS).
* 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.