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Schizophrenia: A Break with Reality – Implications for Dental Care. 26 th Annual Meeting on Special Care Dentistry Chicago, Illinois. What is Schizophrenia?. “YOUTH’S GREATEST DISABLER” commonest form of psychosis affecting mood, thought and behaviour = delusions, hallucinations.

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schizophrenia a break with reality implications for dental care
Schizophrenia: A Break with Reality – Implications for Dental Care

26th Annual Meeting on Special Care Dentistry

Chicago, Illinois

what is schizophrenia
What is Schizophrenia?

“YOUTH’S GREATEST DISABLER”

commonest form of psychosis affecting mood, thought and behaviour = delusions, hallucinations.

one of the most serious of all mental illnesses.

no “cure”

chronic mental illness

CHRONIC MENTAL ILLNESS

“Mental illness doesn’t choose the most talented or the smartest or the richest or poorest. It shows no mercy and often arrives like an unexpected storm, dropping an endless downpour on young dreams” “The Soloist”

Dr. David Clark Ontario Shores CMHS

who gets schizophrenia
Who gets Schizophrenia?

~1- 2% world pop.

onset often late teens/early adulthood - gradual or sudden.

M > F (young age); M=F(adulthood)

Schizophrenia(2006) – $4.35B(Can) $62B(US)

Dr. David Clark Ontario Shores CMHS

slide7
Prevalence: U.S. - ~ 7.2 per 1,000 pop.

Incidence: U.S. - ~ 1 in 4,000 per year.

Dr. David Clark Ontario Shores CMHS

what is the cause of schizophrenia
What is the cause of Schizophrenia?
  • (genetics) altered expression of genes(10-15% with one parent; 30-40% - 2 parents
  • differences in brain chemistry-(imbalances in neurotransmitters, e.g. dopamine)
  • changes in brain structure (MRI,CT,PET)

Dr. David Clark Ontario Shores CMHS

schizophrenia is not
Schizophrenia is NOT:

caused by bad parenting/character flaws

a multiple or “split” personality

the result of childhood trauma

an isolated condition: 10 in 1000 AND 6 will attempt suicide.

an automatic precursor to criminal violence

Dr. David Clark Ontario Shores CMHS

dsm v diagnostic statistical manual of mental disorders
DSM V – Diagnostic & Statistical Manual of Mental Disorders
  • there is no blood test, brain scan or specific x-ray with which to make a diagnosis.
dsm v diagnostic statistical manual of mental disorders1
DSM V – Diagnostic & Statistical Manual of Mental Disorders
  • a “descriptive” approach to diagnosis based on symptoms rather than causes.
  • “clinical significance criterion
schizophrenia
SCHIZOPHRENIA

A diagnosis is further subcategorized according to the dominant presenting symptom:

positive (e.g. paranoia, “voices”)

disorganized (e.g. catatonic)

negative ( e.g. withdrawal).

Dr. David Clark Ontario Shores CMHS

schizophrenia symptoms
SCHIZOPHRENIASymptoms

Positive symptoms: does not mean “good” but s/s that are present but shouldn’t be there.

  • exaggeration of thought
  • distortion of normal function, e.g. delusions (control of one’s thoughts, actions) hallucinations (sensory: auditory- [patient hearing “voices”] visual, tactile)
schizophrenia symptoms1
SCHIZOPHRENIASymptoms

Disorganized symptoms:

  • rapid shift of ideas
  • incoherent speech
  • poor thought relation
  • disorganized, bizarre behaviour e.g.

stereotypical, imitation of others

speech, gestures etc.

schizophrenia symptoms2
SCHIZOPHRENIASymptoms

Negative symptoms: the absences of behaviour thatshould be there.

  • flat affect
  • lack of motivation
  • monotony of speech
  • apathy
  • social withdrawal
  • ***absence of normal drives or interests such as those involving one’s self care (general/oral).
slide21
Dr. David Clark Ontario Shores CMHS

People who DO NOT have a mental disorder commit more than 95% of violent crime in the community….. But the “axe-wielding psycho” is just one of numerous commonly held myths about mental health.

slide22
FACT…..

Dr. David Clark Ontario Shores CMHS

…if we cured schizophrenia, depression and bipolar disorder overnight, >95% of violent crime towards others would still occur in our society…

slide23
FACT…..

….the reality is that patients will harm themselves more than others….

….and they are the victims of crime more than the perpetrators of crime….(2.5% > general population)

violence in metal illness
Violence in metal illness…

Dr. David Clark Ontario Shores CMHS

…associating mental illness with violence helps perpetuate prejudice and discrimination – dangerousness and unpredictability are stereotypes underlying social intolerance….

schizophrenia1
SCHIZOPHRENIA

“Conventional” Antipsychotics

chlorpromazine(Thorazine), methotrimeprazine (Nozinan), haloperidol(Haldol),

Mid-1950s; blocking of dopamine D2 receptors in the basal ganglia/mesolimbic system of the brain affecting mood & thought processes; e.g. wrere effective in managing “positive” symptoms only…. BUT….

Major side effect:tardive dyskinesia (20%); acute dystonia(~2%)

Dr. David Clark Ontario Shores CMHS

schizophrenia2
Schizophrenia

“atypical antipsychotics”

First appeared in late 1980’s

Clozapine (Clozaril)*****

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone** (Zeldox,Geodon)

Dr. David Clark Ontario Shores CMHS

schizophrenia3
Schizophrenia

“atypical antipsychotics”

*rarely cause movement disorders* why? – these drugs possess a high ratio serotonin:D2 activity …therefore referred to as “serotonin-dopamine antagonists” vs. conventional antipsychotics or “dopamine antagonists.”

provide better management of both “positive”, “negative” & “disorganized” symptoms.

Dr. David Clark Ontario Shores CMHS

atypical antipsychotics
Atypical antipsychotics

Often used in the elderly for control of agitation especially in the nursing home setting.

Oral dyskinesia not as prevalent with these drugs.

slide34
FACT…

“adults with serious mental illness treated in the public health systems die about 25 years earlier than Americans overall, a gap that’s widened since the early ’90s when major mental disorders cut life spans by 10 to 15 years”

USA Today - May 3, 2007

Globe & Mail – October 18, 2007

Dr. David Clark Ontario Shores CMHS

slide35
FACT…

“…. the vast majority of people with mental illness die prematurely notbecause of the illnesses attacking their minds, but the ones destroying their hearts….”

Dr. David Clark Ontario Shores CMHS

what is metabolic syndrome
What is Metabolic Syndrome?

Dr. David Clark Ontario Shores CMHS

  • Dysregulation of glucose & lipids predisposing to hyperlipidemia, cardiovascular disease and diabetes.
  • Cardiometabolic risk factors: insulin resistance, HTN, prothrombotic state, pro-inflammatory state, abdominal obesity.
co morbidities resulting from
Co-morbidities resulting from…

Dr. David Clark Ontario Shores CMHS

Preventable/modifiable behaviours

Disease-specific symptoms/behaviours (e.g. depression)

Social deprivation

Homelessness

Poor access

Biased attitudes of HCP’s

and………….

slide39
Issues around

non-compliance

Dr. David Clark Ontario Shores CMHS

schizophrenia4
Schizophrenia

“an illness of impairments in the brain” = psychotic & cognitive symptoms (e.g. memory difficulties).

Cognitive impairments ( parietal lobe) may underlie the reason why 60-80% of patientsmay not believe or recognize that they have the illness.

Therefore… will not seek treatment….will not take prescribed meds…

Dr. David Clark Ontario Shores CMHS

slide42
Obesity associated with caries, hyposalivation, periodontal disease = tooth loss…..

Dental implicationsare also very relevant with respect to overall clinical management of the diabetic, cardiac patient etc.

medication side effects
Medication side-effects

1. Motor side effects( extra-pyramidal side- effects EPS)

  • Parkinsonism – slow, stiffness of limbs, neck; rigid = falls risk!! (acute)
  • Dystonia – spasm of axial muscles e.g. neck(acute)
  • Akathisia – restlessness espec in legs(acute)
  • Tardive dyskinesia – abnormal involuntary movement (chronic)
medication side effects1
Medication side-effects

Dr. David Clark Ontario Shores CMHS

2. Psychiatric side-effects:

  • Sedation –falls risk!!!
  • Apathy
  • Confusion
medication side effects2
Medication side-effects

Dr. David Clark Ontario Shores CMHS

3. Medical complications:

  • Glucose/lipid intolerance – 2-4x higher risk for diabetes.
  • Cardiac conduction problems(arrhythmias)
  • Bone marrow alterations
  • Increase INR (quetiapine)
  • Orthostatic hypotension- falls risk!!!
slide48

…strong connection exists between the health of one’s teeth and a person’s mental health.

Dental health has everything to do with caring for yourself…

slide49
“Ryan”

Case History:

20 y.o. male with schizophrenia

Hx. of self-neglect; social isolation x 4 yrs

Hx. of substance abuse starting age 15

drank ~12 cokes/day+ 1 ppd. smoker

Tx: full mouth ext’n

complete U/L dentures inserted

08-03-03

Dr. David Clark Ontario Shores CMHS

dental perspectives1
Dental Perspectives…..

Dr. David Clark Ontario Shores CMHS

…demonstrate a positive, empathetic, caring and understanding attitude to what may be the more unique needs and differing priorities of our patients dealing with issues of mental illness.

side effects of antipsychotic medications implications for dentistry
Side-effects of antipsychotic medications – implications for dentistry??
  • Excessive sedation – lose interest in eating –weight loss common in elderly
  • Drug-induced EPS – decrease ability to feed oneself; affect choice of foods …
  • Oral dyskinesia – lessen ability to chew/swallow
  • Esophageal dysmotility – choking behaviours
  • Dry mouth – chewing/swallowing
antipsychotic medications
Antipsychotic medications

Dr. David Clark Ontario Shores CMHS

  • judicious use of epinephrine(L.A.) – orthostatic hypotension
  • potentiation of other sedative, hypnotic, narcotic agents
  • bone marrow suppression(clozapine)
  • neuroleptic malignant syndrome
schizophrenia oro facial findings
Schizophrenia: Oro-facial findings

Saliva:A Precious Body Fluid

Xerostomia

dry mouth xerostomia
DRY MOUTH/XEROSTOMIA

Can lead to:

  • Choking, dysphagia
  • Difficulty speaking
  • Dental decay
  • Bad breath
  • Dysgeusia, burning sensation
  • Swollen, red tongue; candidiasis
  • Painful, bleeding gums
  • Difficulty keeping dentures in
schizophrenia oro facial findings1
Schizophrenia: Oro-facial findings

Dr. David Clark Ontario Shores CMHS

Poor oral hygiene

Rampant dental decay

(can in turn be a separate stigma producing influence against overall patient rehabilitation & recovery!!)

schizophrenia management with clozapine
Schizophrenia:Management with Clozapine

Clozapine-inducedhypersalivation

1/3 of cases, early in treatment, nighttime

stigmatizing with inc. rates of non-compliance

Why?

antagonist M3/agonist M4(muscarinic receptors) = hypersalivation

impaired swallowing mechanism=pooling of saliva=hypersalivation

schizophrenia oro facial findings2
Schizophrenia: Oro-facial findings

Dr. David Clark Ontario Shores CMHS

schizophrenia medication side effects
SchizophreniaMedication Side Effects

Tardive Dyskinesia: a side effect of longstanding use of antipsychotic medication - ~ 20% of patients; higher risk in elderly earlier on in tx.

Abnormal involuntary movement of the tongue, facial/neck muscles, extremities and trunk.

schizophrenia medication side effects1
SchizophreniaMedication Side Effects

Involuntary tongue movements = tongue thrusting/protrusions; lip smacking; puckering of lips; chewing movements; cheek puffing; repetitive movements of the extremities and trunk

schizophrenia oro facial findings3
Schizophrenia: Oro-facial findings

Dr. David Clark Ontario Shores CMHS

Delusional thinking focusing on the oral cavity.

delusional thinking
Delusional thinking…

Dr. David Clark Ontario Shores CMHS

  • placement of transmitters into teeth
  • oro-facial/self-mutilation –cheek biting, lip biting
  • excoriation of gingiva
  • burning of oral tissues e.g. cigarette
schizophrenia other oral f indings
Schizophrenia…other oral findings
  • higher prevalence of bruxism and signs of TMD = severe tooth damage due to extensive attrition.
  • ? CNS abnormalities and/or neuroleptic induced mechanisms.
  • actual pain sensitivity thresholds higher in pats. with schizophrenia vs. healthy controls.
  • pain sensitivity thresholds cause delays in diagnosis and Tx. resulting in serious clinical consequences.

Triple O Journal- Jan.2007

clozapine

CLOZAPINE

limiting factor for use:

AGRANULOCYTOSIS <3000 wbc/c.c.

-1-2% risk

-patients require routine biweekly bloodwork

-we need to know!

slide68

Should be used in caution in people on psychotropic medications due to potential for initiating a hypotensive reaction and increased risk of hallucination in psychotic patients.

  • Use of N20 in recovered alcoholics and drug abusers could increase the risk of relapse.

Dr. David Clark

so what can we do
So…. what can we do??

Dr. David Clark Ontario Shores CMHS

CLIENT EDUCATION and REINFORCEMENT of DENTAL SELF-CARE – build awareness wherever/whenever possible….

treatment planning
Treatment Planning

Dr. David Clark Ontario Shores CMHS

Consult with GP/psychiatrist –ensure stability, control, capacity to consent.

Be flexible and dynamic

Positive attitude

Aggressive on prevention- frequent use of auxiliary preventive agents

Morning appointments(?)

possible guidelines for communication with patients with cmi
Persons with MI:

have trouble with “reality”…………

are fearful………...

are insecure……...

have trouble concentrating.....

So you need to…

be simple, truthful

stay calm

be accepting

be brief, repeat

Possible guidelines for communication with patients with CMI
possible guidelines for communication with patients with cmi1
Persons with MI:

easily agitated…………

poor judgment……

are over stimulated………

So you need to…

recognize

agitation, allow escape

not expect rational discussion

limit input, not force discussion

Possible guidelines for communication with patients with CMI
possible guidelines for communication with patients with cmi2
Persons with MI:

are preoccupied………

have changing plans…

believe delusions…….

have low self-esteem, lack motivation…….

So you need to…

get attention first

stick to one plan

ignore, don’t argue

stay positive!!!

Possible guidelines for communication with patients with CMI
conclusion
Conclusion

Oral health can reflect a record of the peaks and valleys of a person’s life i.e. the times when people are healthy and the times when they stop caring for themselves e.g. psychosis, depression etc.

Dr. David Clark

contact information
Contact Information

Dr. David Clark

BSc. DDS, MSc.(Oral Path) FAAOP, FRCDC

Director, Dental Services

Ontario Shores Centre

for Mental Health Sciences

700 Gordon Street

Whitby, Ontario, CANADA

L1N 5S9

(905)430-4033 ext 6168

clarkd@ontarioshores.ca

davidclark1461@gmail.com

Clinical Associate in Dentistry (part-time)

Dept. of Oral Medicine

Faculty of Dentistry

University of Toronto