Schizophrenia: A Break with Reality – Implications for Dental Care
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Transcript of 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?“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
“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?
~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
Dr. David Clark Ontario Shores CMHS
Dr. David Clark Ontario Shores CMHS
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?
(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
Dr. David Clark Ontario Shores CMHS
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
How is the diagnosis of Schizophrenia made?
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 Disorders
a “descriptive” approach to diagnosis based on symptoms rather than causes.
“clinical significance criterion
What are the symptoms of 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
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)
SCHIZOPHRENIASymptoms
Disorganized symptoms: rapid shift of ideas incoherent speech poor thought relation disorganized, bizarre behaviour e.g.
stereotypical, imitation of others
speech, gestures etc.
SCHIZOPHRENIASymptoms
Negative symptoms: the absences of behaviour that should 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).
SYMPTOM MANIFESTATIONPositive - Hallucinations Auditory, command type, tactile (electrical,
tingling, burning sensation) somatic
Positive - Delusions Persecutory type, reference type, thought broadcasting, thought insertion, thought withdrawal, being controlled by others
Negative - Disturbances of Affect
Absence of emotion, monotony of speech, cold and incongruous attitude, lack of expression
Negative - Impaired interpersonal relationships
Social withdrawal, emotional detachment
Disorganized - Psychomotor Disturbances
Grimacing, repetitive and awkward movements, rigidity, mutism, pacing
Disorganized - Thought Disturbances
Incoherent speech, rapid shift of ideas, poor relation of thoughts
Disorganized Ritualistic, stereotypical behaviour
Negative - Lack of self-care, motivation, initiative
***Poor oral/general hygiene, dental caries, periodontal disease***
What about Schizophrenia and violence?
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.
Dr. David Clark Ontario Shores CMHS
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…
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…
Dr. David Clark Ontario Shores CMHS
…associating mental illness with violence helps perpetuate prejudice and discrimination – dangerousness and unpredictability are stereotypes underlying social intolerance….
Schizophrenia:
Historical Treatments
Dr. David Clark
Pharmacological Treatment
ANTIPSYCHOTICS
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
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
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
Often used in the elderly for control of agitation especially in the nursing home setting.
Oral dyskinesia not as prevalent with these drugs.
Dr. David Clark Ontario Shores CMHS
How does Schizophrenia relate to one’s general health?
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, 2007Globe & Mail – October 18, 2007
Dr. David Clark Ontario Shores CMHS
FACT…
“…. the vast majority of people with mental illness die prematurely
not because of the illnesses attacking their minds, but the ones destroying their
hearts….”
Dr. David Clark Ontario Shores CMHS
What is Metabolic Syndrome?
Dysregulation of glucose & lipids predisposing to hyperlipidemia, cardiovascular disease and diabetes.
Cardiometabolic risk factors: insulin
resistance, HTN, prothrombotic state, pro-inflammatory state, abdominal obesity.
Dr. David Clark Ontario Shores CMHS
Causes of Death
020406080
100
GeneralPopulation
Serious MentalIllness
OtherCVD
Dr. David Clark Ontario Shores CMHS
Co-morbidities resulting from…
Preventable/modifiable behaviours Disease-specific symptoms/behaviours
(e.g. depression) Social deprivation Homelessness Poor access Biased attitudes of HCP’s and………….
Dr. David Clark Ontario Shores CMHS
Issues around non-compliance
Dr. David Clark Ontario Shores CMHS
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 patients may 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
Patient Specific Factors in Schizophrenia
Factor Prevalence in schizophrenia
Prevalence in general pop.
Smoking 65% 21%
Obesity 50% 33%
Diabetes 14% 7%
HIV 3% 0.3%
Hepatitis C 20% 1.8%Other: inactivity,poor nutrition,substance abuse
Obesity associated with caries, hyposalivation, periodontal
disease = tooth loss…..
Dental implications are also very relevant with respect to
overall clinical management of the diabetic, cardiac patient etc.
Medication side-effects1. 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-effects2. Psychiatric side-effects:
Sedation –falls risk!!! Apathy Confusion
Dr. David Clark Ontario Shores CMHS
Medication side-effects3. 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!!!
Dr. David Clark Ontario Shores CMHS
DENTAL PERSPECTIVES
How does Schizophrenia affect one’s oral health?
…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…
“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
08-03-03Dr. David Clark Ontario Shores CMHS
Dental Perspectives…..…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.
Dr. David Clark Ontario Shores CMHS
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
judicious use of epinephrine(L.A.) – orthostatic hypotension
potentiation of other sedative, hypnotic, narcotic agents
bone marrow suppression(clozapine) neuroleptic malignant syndrome
Dr. David Clark Ontario Shores CMHS
Schizophrenia: Oro-facial findings
XerostomiaSaliva:
A Precious Body Fluid
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 findings
Dr. David Clark Ontario Shores CMHS
Poor oral hygieneRampant dental decay(can in turn be a separate stigma producing influence against overall patient rehabilitation & recovery!!)
Dr. David Clark Ontario Shores CMHS
Schizophrenia:Management with Clozapine
Clozapine-induced hypersalivation1/3 of cases, early in treatment, nighttimestigmatizing with inc. rates of non-
complianceWhy?antagonist M3/agonist M4(muscarinic
receptors) = hypersalivationimpaired swallowing mechanism=pooling
of saliva=hypersalivation
Schizophrenia: Oro-facial findings
Dr. David Clark Ontario Shores CMHS
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.
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 findings
Dr. David Clark Ontario Shores CMHS
Delusional thinking focusing on the oral cavity.
Delusional thinking… placement of transmitters into teeth oro-facial/self-mutilation –cheek biting, lip
biting excoriation of gingiva burning of oral tissues e.g. cigarette
Dr. David Clark Ontario Shores CMHS
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
CLOZAPINElimiting factor for use:
AGRANULOCYTOSIS <3000 wbc/c.c.
-1-2% risk-patients require routine
biweekly bloodwork-we need to know!
METH MOUTH
What about NITROUS OXIDE (N20)?
• 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??
Dr. David Clark Ontario Shores CMHS
CLIENT EDUCATION and REINFORCEMENT of DENTAL SELF-CARE – build awareness wherever/whenever possible….
Treatment Planning 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(?)
Dr. David Clark Ontario Shores CMHS
Possible guidelines for communication with patients
with CMIPersons with MI:have trouble with
“reality”…………
are fearful………...are insecure……...have trouble
concentrating.....
So you need to…be simple, truthful
stay calmbe accepting
be brief, repeat
Possible guidelines for communication with patients
with CMIPersons with MI:easily
agitated…………
poor judgment……
are over stimulated………
So you need to…recognize agitation, allow
escapenot expect rational
discussion
limit input, not force discussion
Possible guidelines for communication with patients
with CMIPersons 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 planignore, don’t argue
stay positive!!!
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
Dr. David Clark BSc. DDS, MSc.(Oral Path)
FAAOP, FRCDC Director, Dental ServicesOntario Shores Centre for Mental Health Sciences700 Gordon StreetWhitby, Ontario, CANADA L1N 5S9(905)430-4033 ext [email protected]@gmail.com
Clinical Associate in Dentistry (part-time)
Dept. of Oral Medicine
Faculty of Dentistry
University of Toronto