Schizophrenia: A Break with Reality * Implications for Dental Care

Report
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
SCHIZOPHRENIA
Symptoms
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
Symptoms
Disorganized symptoms:

rapid shift of ideas

incoherent speech

poor thought relation

disorganized, bizarre behaviour e.g.
stereotypical, imitation of others
speech, gestures etc.
SCHIZOPHRENIA
Symptoms
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
MANIFESTATION
Positive - 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 selfcare, 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 “axewielding psycho” is just one of
numerous commonly held myths
about mental health.
Dr. David Clark Ontario Shores CMHS
FACT…..
…if we cured schizophrenia,
depression and bipolar disorder
overnight, >95% of violent crime
towards others would still occur
in our society…
Dr. David Clark Ontario Shores CMHS
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….
Dr. David Clark Ontario Shores CMHS
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
dystonia(~2%)
dyskinesia (20%); acute
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, 2007
Globe & 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, proinflammatory state, abdominal obesity.
Dr. David Clark Ontario Shores CMHS
Causes of Death
100
80
60
Other
40
CVD
20
0
General
Population
Serious Mental
Illness
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
Smoking
Prevalence in
schizophrenia
65%
Prevalence in
general pop.
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-effects
1. Motor side effects( extra-pyramidal sideeffects 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-effects
2. Psychiatric side-effects:
 Sedation –falls risk!!!
 Apathy
 Confusion
Dr. David Clark Ontario Shores CMHS
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
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
08-03-03
Dr. 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
Xerostomia
Saliva:
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
Poor oral hygiene
Rampant dental decay
(can in turn be a separate stigma
producing influence against overall
patient rehabilitation & recovery!!)
Dr. David Clark Ontario Shores CMHS
Dr. David Clark Ontario Shores CMHS
Schizophrenia:
Management with Clozapine
Clozapine-induced hypersalivation
1/3 of cases, early in treatment, nighttime
stigmatizing with inc. rates of noncompliance
Why?
antagonist M3/agonist M4(muscarinic
receptors) = hypersalivation
impaired swallowing mechanism=pooling
of saliva=hypersalivation
Schizophrenia: Oro-facial
findings
Dr. David Clark Ontario Shores CMHS
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.
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
Schizophrenia: Oro-facial
findings
Delusional thinking
focusing on the oral
cavity.
Dr. David Clark Ontario Shores CMHS
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
CLOZAPINE
limiting 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….
Dr. David Clark Ontario Shores CMHS
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 CMI
Persons with MI:
have trouble with
“reality”…………
So you need to…
be simple, truthful
are fearful………... stay calm
are insecure……... be accepting
have trouble
concentrating..... be brief, repeat
Possible guidelines for
communication with patients
with CMI
So you need to…
Persons with MI:
recognize
easily
agitated………… agitation, allow
escape
poor judgment…… not expect rational
discussion
are over
stimulated……… limit input, not
force discussion
Possible guidelines for
communication with patients
with CMI
Persons with MI:
are preoccupied………
have changing plans…
So you need to…
get attention first
believe delusions…….
stick to one plan
ignore, don’t argue
have low self-esteem,
lack motivation…….
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
Clinical Associate in Dentistry
(part-time)
Dept. of Oral Medicine
Faculty of Dentistry
University of Toronto
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

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