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

http://en.wikipedia.org/wiki/File:SoloistPoster.jpg

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)




Prevalence: U.S. - ~ 7.2 per 1,000 pop.Incidence: U.S. - ~ 1 in 4,000 per year.


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)



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


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).


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)


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

stereotypical, imitation of others

speech, gestures etc.


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.


FACT…..


…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…


…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%)


Schizophrenia

“atypical antipsychotics”First appeared in late 1980’s

Clozapine (Clozaril)***** Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel)

Ziprasidone** (Zeldox,Geodon)


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.


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.


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


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….”


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.


Causes of Death

020406080

100

GeneralPopulation

Serious MentalIllness

OtherCVD


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………….


Issues around non-compliance


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…


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


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!!!


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.


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


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



Poor oral hygieneRampant dental decay(can in turn be a separate stigma producing influence against overall patient rehabilitation & recovery!!)


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



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



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


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??


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(?)


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


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


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

Documents

Schizophrenia: A Break with Reality – Implications for Dental Care