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Schizophrenia: A Break with Reality – Implications for Dental Care 26 th Annual Meeting on Special Care Dentistry Chicago, Illinois.

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Presentation on theme: "Schizophrenia: A Break with Reality – Implications for Dental Care 26 th Annual Meeting on Special Care Dentistry Chicago, Illinois."— Presentation transcript:

1 Schizophrenia: A Break with Reality – Implications for Dental Care 26 th Annual Meeting on Special Care Dentistry Chicago, Illinois

2 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”

3 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

4 Who gets Schizophrenia? ~1- 2% world pop. ~1- 2% world pop. onset often late teens/early adulthood - gradual or sudden. onset often late teens/early adulthood - gradual or sudden. M > F (young age); M=F(adulthood) M > F (young age); M=F(adulthood) Schizophrenia(2006) – $4.35B(Can) $62B(US) Schizophrenia(2006) – $4.35B(Can) $62B(US) Dr. David Clark Ontario Shores CMHS

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7 Prevalence: U.S. - ~ 7.2 per 1,000 pop. Incidence: U.S. - ~ 1 in 4,000 per year. Dr. David Clark Ontario Shores CMHS

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

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10 Schizophrenia is NOT: caused by bad parenting/character flaws caused by bad parenting/character flaws a multiple or “split” personality a multiple or “split” personality the result of childhood trauma the result of childhood trauma an isolated condition: 10 in 1000 AND 6 will attempt suicide. an isolated condition: 10 in 1000 AND 6 will attempt suicide. an automatic precursor to criminal violence an automatic precursor to criminal violence Dr. David Clark Ontario Shores CMHS

11 How is the diagnosis of Schizophrenia made?

12 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. there is no blood test, brain scan or specific x-ray with which to make a diagnosis.

13 DSM V – Diagnostic & Statistical Manual of Mental Disorders a “descriptive” approach to diagnosis based on symptoms rather than causes. a “descriptive” approach to diagnosis based on symptoms rather than causes. “clinical significance criterion “clinical significance criterion

14 What are the symptoms of Schizophrenia?

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

16 SCHIZOPHRENIA Symptoms Positive symptoms: does not mean “good” but s/s that are present but shouldn’t be there. exaggeration of thought exaggeration of thought distortion of normal function, e.g. delusions (control of one’s thoughts, actions) hallucinations (sensory: auditory- [patient hearing “voices”] visual, tactile) distortion of normal function, e.g. delusions (control of one’s thoughts, actions) hallucinations (sensory: auditory- [patient hearing “voices”] visual, tactile)

17 SCHIZOPHRENIA Symptoms Disorganized symptoms: rapid shift of ideas rapid shift of ideas incoherent speech incoherent speech poor thought relation poor thought relation disorganized, bizarre behaviour e.g. disorganized, bizarre behaviour e.g. stereotypical, imitation of others stereotypical, imitation of others speech, gestures etc. speech, gestures etc.

18 SCHIZOPHRENIA Symptoms Negative symptoms: the absences of behaviour that should be there. flat affect flat affect lack of motivation lack of motivation monotony of speech monotony of speech apathy apathy social withdrawal social withdrawal ***absence of normal drives or interests such as those involving one’s self care (general/oral). ***absence of normal drives or interests such as those involving one’s self care (general/oral).

19 SYMPTOM MANIFESTATION Positive - HallucinationsAuditory, command type, tactile (electrical, tingling, burning sensation) somatic Positive - DelusionsPersecutory 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 DisorganizedRitualistic, stereotypical behaviour Negative - Lack of self- care, motivation, initiative ***Poor oral/general hygiene, dental caries, periodontal disease***

20 What about Schizophrenia and violence?

21 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. 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

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

23 FACT….. 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)

24 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….

25 Schizophrenia: Historical Treatments

26 Dr. David Clark

27 Pharmacological Treatment ANTIPSYCHOTICS

28 SCHIZOPHRENIASCHIZOPHRENIA “Conventional” Antipsychotics chlorpromazine(Thorazine), methotrimeprazine (Nozinan), haloperidol(Haldol), 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

29 SchizophreniaSchizophrenia “atypical antipsychotics” First appeared in late 1980’s Clozapine (Clozaril)***** Risperidone (Risperdal) Olanzapine (Zyprexa) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone** (Zeldox,Geodon) Dr. David Clark Ontario Shores CMHS

30 Schizophrenia 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.” *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. provide better management of both “positive”, “negative” & “disorganized” symptoms. Dr. David Clark Ontario Shores CMHS

31 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.

32 Dr. David Clark Ontario Shores CMHS

33 How does Schizophrenia relate to one’s general health?

34 FACT…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

35 FACT…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

36 What is Metabolic Syndrome? Dysregulation of glucose & lipids predisposing to hyperlipidemia, cardiovascular disease and diabetes. Dysregulation of glucose & lipids predisposing to hyperlipidemia, cardiovascular disease and diabetes. Cardiometabolic risk factors: insulin resistance, HTN, prothrombotic state, pro- inflammatory state, abdominal obesity. Cardiometabolic risk factors: insulin resistance, HTN, prothrombotic state, pro- inflammatory state, abdominal obesity. Dr. David Clark Ontario Shores CMHS

37 23%Up to 85%Smoking Gen. PopulationSchizophreniaCo-morbidity Goff et al. J Clin Psych, 2005 Sokal et al. J Nerv Ment Disord, 2004 Carney et al. J Gen Intern Med, 2006 0.2% Up to 9.3%Hepatic Disease Up to 1.8%Up to 19.9%Hep C 0.3%3 to 6%HIV 8%Up to 15%Diabetes 22%Up to 50%Cardiovascular Disease Medical Co-morbidities

38 Dr. David Clark Ontario Shores CMHS

39 Co-morbidities resulting from… Preventable/modifiable behaviours Preventable/modifiable behaviours Disease-specific symptoms/behaviours (e.g. depression) Disease-specific symptoms/behaviours (e.g. depression) Social deprivation Social deprivation Homelessness Homelessness Poor access Poor access Biased attitudes of HCP’s Biased attitudes of HCP’s and…………. and…………. Dr. David Clark Ontario Shores CMHS

40 Issues around non-compliance Dr. David Clark Ontario Shores CMHS

41 SchizophreniaSchizophrenia “an illness of impairments in the brain” = psychotic & cognitive symptoms (e.g. memory difficulties). “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. 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… Therefore… will not seek treatment….will not take prescribed meds… Dr. David Clark Ontario Shores CMHS

42 Patient Specific Factors in Schizophrenia FactorPrevalence in schizophrenia Prevalence in general pop. Smoking65%21% Obesity50%33% Diabetes14%7% HIV3%0.3% Hepatitis C20%1.8% Other: inactivity, poor nutrition, substance abuse

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

44 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)

45 Medication side-effects 2. Psychiatric side-effects:  Sedation –falls risk!!!  Apathy  Confusion Dr. David Clark Ontario Shores CMHS

46 Medication side-effects 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!!! Dr. David Clark Ontario Shores CMHS

47 DENTAL PERSPECTIVES

48 How does Schizophrenia affect one’s oral health?

49 …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…

50 “Ryan” Case History: 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 complete U/L dentures inserted 08-03-03 08-03-03 Dr. David Clark Ontario Shores CMHS

51 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

52 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

53 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

54 Schizophrenia: Oro-facial findings Xerostomia Saliva: A Precious Body Fluid

55 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

56 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!!)

57 Dr. David Clark Ontario Shores CMHS

58 Schizophrenia: Management with Clozapine Clozapine-induced hypersalivation  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

59 Schizophrenia: Oro-facial findings Dr. David Clark Ontario Shores CMHS

60 Schizophrenia Medication 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.

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

62 Schizophrenia: Oro-facial findings Dr. David Clark Ontario Shores CMHS Delusional thinking focusing on the oral cavity.

63 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

64 Schizophrenia …other oral findings higher prevalence of bruxism and signs of TMD = severe tooth damage due to extensive attrition. higher prevalence of bruxism and signs of TMD = severe tooth damage due to extensive attrition. ? CNS abnormalities and/or neuroleptic induced mechanisms. ? CNS abnormalities and/or neuroleptic induced mechanisms. actual pain sensitivity thresholds higher in pats. with schizophrenia vs. healthy controls. 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. pain sensitivity thresholds cause delays in diagnosis and Tx. resulting in serious clinical consequences. Triple O Journal- Jan.2007 Triple O Journal- Jan.2007

65 CLOZAPINE limiting factor for use: AGRANULOCYTOSIS <3000 wbc/c.c. -1-2% risk -patients require routine biweekly bloodwork -we need to know!

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68 What about NITROUS OXIDE (N20)?

69 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

70 So…. what can we do?? Dr. David Clark Ontario Shores CMHS CLIENT EDUCATION and REINFORCEMENT of DENTAL SELF-CARE – build awareness wherever/whenever possible….

71 Treatment Planning Consult with GP/psychiatrist –ensure stability, control, capacity to consent. Consult with GP/psychiatrist –ensure stability, control, capacity to consent. Be flexible and dynamic Be flexible and dynamic Positive attitude Positive attitude Aggressive on prevention- frequent use of auxiliary preventive agents Aggressive on prevention- frequent use of auxiliary preventive agents Morning appointments(?) Morning appointments(?) Dr. David Clark Ontario Shores CMHS

72 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

73 Possible guidelines for communication with patients with CMI 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

74 Possible guidelines for communication with patients with CMI 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!!!

75 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

76 Contact Information Dr. David Clark BSc. DDS, MSc.(Oral Path) FAAOP, FRCDC BSc. DDS, MSc.(Oral Path) FAAOP, FRCDC Director, Dental Services Ontario Shores Centre for Mental Health Sciences for Mental Health Sciences 700 Gordon Street Whitby, Ontario, CANADA L1N 5S9 L1N 5S9 (905)430-4033 ext 6168 clarkd@ontarioshores.cadavidclark1461@gmail.com Clinical Associate in Dentistry (part-time) Clinical Associate in Dentistry (part-time) Dept. of Oral Medicine Dept. of Oral Medicine Faculty of Dentistry Faculty of Dentistry University of Toronto University of Toronto


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